chapter 59 medical supplier manual - new jersey...

Division of Medical Assistance and Health Services MEDICAL SUPPLIER SERVICES MANUAL

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CHAPTER 59

MEDICAL SUPPLIER MANUAL


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TABLE OF CONTENTS SUBCHAPTER 1. MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT 10:59-1.1 Introduction 10:59-1.2 Definitions 10:59-1.3 Requirements for program participation as a medical supplier 10:59-1.4 Non-covered items or services 10:59-1.5 Policy for providing medical supplies and DME 10:59-1.6 Prior authorization (PA) 10:59-1.7 Policy considerations for purchase, rental and repair of DME 10:59-1.8 Basis of reimbursement for medical supplies and DME 10:59-1.9 Dual Medicare/Medicaid or NJ KidCare coverage 10:59-1.10 Third party liability (TPL), excluding Medicare 10:59-1.11 Recycling durable medical equipment 10:59-1.12 Parenteral therapy 10:59-1.13 Augmentative/alternative communication system (ACS) 10:59-1.14 Pressure reduction systems 10:59-1.15 Apnea monitor SUBCHAPTER 2. HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS) 10:59-2.1 Introduction 10:59-2.2 Elements of HCPCS Coding System which require the attention of the provider 10:59-2.3 HCPCS procedure codes and maximum fee allowance schedule for medical supplies and durable medical equipment APPENDIX A: SERVICE STATUS AND PA REQUIREMENTS FOR HCPCS CODES APPENDIX B: FISCAL AGENT BILLING SUPPLEMENT


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SUBCHAPTER 1. MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT 10:59-1.1 Introduction This chapter outlines the policies and procedures of the New Jersey Medicaid program relevant to medical supplies and durable medical equipment, including enteral, total parenteral nutrition and other intravenous therapies. This chapter provides specific requirements that must be met by a Medical Supplier to qualify for reimbursement under the New Jersey Medicaid program. 10:59-1.2 Definitions The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise: "Apnea monitor" means an electronic device used to measure respiration and cardiac functions in patients experiencing episodic apnea related to a medical diagnosis or a predisposition of apneic episodes based on genetic or familial history. "Augmentative/Alternative Communication System (ACS)" means communication systems, commercially available or custom designed, which are appropriate for children or adults whose ability to communicate orally or in writing is severely impaired and who have mental potential to benefit from ACS. ACS includes, but is not restricted to, non-electronic devices and electronic/computerized devices. "Customized" DME means an item of DME which has been fabricated by the provider to meet the specialized needs, physical characteristics and/or deformities of a beneficiary. "DMERC" means the Durable Medical Equipment Regional Carrier approved by the Health Care Financing Administration. "Durable medical equipment" (DME) as defined for this subchapter, means an item or apparatus, other than hearing aids and certain prosthetic and orthotic devices, including customized DME, modified DME and standard DME, which has all of the following characteristics: 1. Is primarily and customarily prescribed to serve a medical purpose and is medically necessary for the beneficiary for whom requested; 2. Is generally not useful to a beneficiary in the absence of a disease, illness, injury, or disability; and 3. Is capable of withstanding repeated use (durable) and is nonexpendable; for example, hospital bed, oxygen equipment, wheelchair, walker, suction equipment, and the like. "Invoice" means an unaltered document reflecting a supplier's actual acquisition cost,


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which shows the supplier as the addressee, item description, quantity, and cost. "Maximum fee allowance" means the Medicaid maximum payment assigned to medical supplies and DME. "Medical supplier" means a provider of medical supplies and/or durable medical equipment. "Medical supplies" means item(s) which are: 1. Consumable, expendable, disposable or non-durable; 2. Prescribed by a practitioner; and 3. Medically necessary for use by an eligible beneficiary. "Modified DME" means a standard item of DME which is modified to meet the specialized needs of a beneficiary by adding non-standard parts. "Nursing facility (NF)" means an institution (or distinct part of an institution) certified by the New Jersey State Department of Health and Senior Services for participation in Title XIX Medicaid and primarily engaged in providing health-related care and services on a 24-hour basis to Medicaid beneficiaries (children and adults) who, due to medical disorders, developmental disabilities and/or related cognitive and behavioral impairments, exhibit the need for medical, nursing, rehabilitative, and psychosocial management above the level of room and board, but not primarily for care and treatment of mental diseases which require continuous 24-hour supervision by qualified mental health professionals or the provision of parenting needs related to growth and development. (See N.J.A.C. 10:63.) "Pressure reduction system" means a system which incorporates simple or complex equipment designed to reduce support surface pressures by powered or non-powered means for the purpose of encouraging healing of decubiti. "Price list" means any unaltered document published by a manufacturer which is used in place of an invoice by the fiscal agent to price a "by report" procedure code which includes a manufacturer's name, item description, and suggested retail price per unit or package and a notation by a supplier indicating the number of units per package, if not described by a manufacturer. "Recycled" when referring to a DME item, means an item purchased by the New Jersey Medicaid Program that is no longer medically needed by the Medicaid beneficiary, that at a minimum will be sanitized and refurbished and/or repaired, if needed, by the DME provider and supplied to another beneficiary.


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"Standard" DME means DME which is available without modification. "Usual and customary" means a medical supplier's charge to the general public for services rendered which equals the supplier's submitted price to the Medicaid program.

CASE NOTES Medical necessity authorized purchase of thermal scan thermometer with Medicaid funds for severely retarded child. C.F. v. Division of Medical Assistance, 95 N.J.A.R.2d (DMA) 45. Adapted tricycle was medically required for treating chronic encephalopathy. K.H. v. Division of Medical Assistance and Health Services, 93 N.J.A.R.2d (DMA) 3. 10:59-1.3 Requirements for program participation as a medical supplier (a) In order to participate in New Jersey Medicaid program, a medical supplier shall: 1. Be an established place of business as a medical supplier in New Jersey; or 2. Be a pharmacy operating under a valid permit issued by the New Jersey State Board of Pharmacy; or 3. Be an out-of-State pharmacy or medical supplier who is an approved Medicaid provider in their state of residence. (b) In order to participate in the New Jersey Medicaid Program, a medical supplier shall: 1. Maintain a previously approved or fixed, established place of business located in a commercial zone which shall be open and accessible to the general public during normal business hours; 2. Display a sign of identification, external to the interior business site, visually recognized by the general public; 3. Receive approval from the New Jersey Medicaid program for each site from which equipment and supplies are distributed and/or delivered; 4. Comply with the requirements described at N.J.A.C. 10:49-3.2 if the medical supplier is to fill a prescription written by a physician or other practitioner who has an ownership interest in the supplier's business; 5. Notify the State's fiscal agent and file a new application within 60 days of a change in ownership and/or location; and 6. Agree to permit properly identified representatives of the New Jersey Medicaid program to: i. Inspect the original prescription or the Certificate of Medical Necessity (CMN) on file; ii. Audit records pertaining to costs of medical supplies and equipment provided to Medicaid beneficiaries; and


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iii. Inspect private sector records, where deemed necessary, to comply with Federal regulations to determine a provider's usual and customary charge to the public. 10:59-1.4 Non-covered items or services (a) The New Jersey Medicaid program does not cover medical supplies and durable medical equipment under the following conditions: 1. A particular item of DME is not covered when, in the opinion of the Division, the item is not considered cost-effective or safe and effective for the treatment of a beneficiary's medical condition; 2. Items available without charge through programs of other public or voluntary agencies (for example: New Jersey State Department of Health and Senior Services, Heart Association, American Cancer Society) are not covered; 3. Supplies which are administered or directly furnished by practitioners or by home health agencies as part of per visit reimbursement are not covered separately; 4. Medical supplies, routinely used DME and other therapeutic equipment/supplies essential to furnish the services offered by a facility for the care and treatment of its residents are considered part of the NF's per diem and therefore, not covered. Examples of this type of equipment and supplies include, but are not limited to, the following: i. Administration pumps; ii. Aspirators; iii. Canes; iv. Communication equipment (life-safety devices including alarms and apnea monitors); v. Crutches; vi. Enteral nutritional supplements and related supplies (including IV poles and enteral pumps); vii. Geri-chairs; viii. Hospital beds (including mattress and side rails); ix. IPPB machines; x. IV supplies and related equipment; xi. Lifts; xii. Low end pressure relief systems, for example, mattress overlays, mattress replacements, powered mattress systems and air powered flotation beds; xiii. Nebulizers; xiv. Oxygen and related equipment; xv. Traction apparatus; xvi. Walkers; xvii. Standard wheelchairs and accessories including adjustable leg rests and detachable armrests; and xviii. Medical supplies, for example, incontinency pads, bandages, dressings, compresses, sponges, plasters, tapes, cellu-cotton or other types of pads used to save


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labor or linen, colostomy bags, hot water bags, thermometers, catheters, rubber gloves, and disposable syringes. 5. Exceptions to (a)4 above include certain durable medical equipment not routinely used in a nursing facility and which is required due to the medical need of the individual resident; 6. Items not meeting the definitions of medical supplies and DME outlined at N.J.A.C. 10:59-1.2, Definitions; 7. Delivery and shipping costs; 8. Services being provided to a beneficiary who loses eligibility, except as described at N.J.A.C. 10:49-5.4(a)9; and 9. Travel time, except for services provided by a pedorthist. (b) Non-covered items include, but are not limited to, the following: 1. Bags (douche, enema, ice); 2. Beds (waterbeds); 3. Environmental control equipment, including electronic devices intended to control or alter the environment, such as lighting, telephones and appliances; air conditioners; humidifiers; dehumidifiers and air filtering systems with the exception of vaporizers and cool mist humidifiers; 4. Exercise equipment; 5. Eye patches; 6. First aid supplies or medicine chest items (gauze, adhesive tape, bandages, and cotton); 7. Footwear, orthopedic, and foot orthotics, except when attached to a brace or bar or when part of a normal post-operative or post-fracture treatment program, or when used to correct or adapt to gross foot deformities (see N.J.A.C. 10:57); 8. Hot water bottles; 9. Infant formula (standard); 10. Inflatable rubber invalid rings; 11. Lifts (chair or seat); 12. Mattresses (orthopedic or mattresses without FDA approval); 13. Nasal aspirators; 14. Pads (heating, hydrocollators, sanitary, thermophore); 15. Personal incidentals, including items for personal cleanliness, body hygiene, and grooming, for example, standard toothbrushes, mouthwashes, dentifrices, deodorant soaps, cosmetics, shaving items, and so forth; 16. Plastic gloves; 17. Protein nutritional supplements in which the quantity dispensed exceeds a 34-day supply; 18. Scales (bathroom); 19. Specialized infant formulas in which the quantity dispensed exceeds a 34- day supply;


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20. Stainless steel bedpans or urinals; 21. Syringes (bulb, enema); 22. Thermometers (axillary, ear, oral, rectal); and 23. Tongue blades (sterile, non-sterile).

CASE NOTES Nonambulatory, wheelchair-dependent 14-year-old boy with cerebral palsy, spastic quadriplegia and seizure disorder denied electric stair glide. D.J. v. Essex County Division of Welfare, 94 N.J.A.R.2d (DMA) 47. Judge's allowance of reimbursement for purchase of HEPA Air Cleaner reversed as electrostatic air filter reimbursement is specifically prohibited by regulation. In the Matter of M.D., 7 N.J.A.R. 254 (1980), reversed 179 N.J.Super. 541, 432 A.2d 943, (App.Div.1981), modified in part and remanded 91 N.J. 1, 449 A.2d 1235 (1982). 10:59-1.5 Policy for providing medical supplies and DME (a) Medical supplies and equipment require a legible, dated prescription or a Certificate of Medical Necessity (CMN) personally signed by the prescribing practitioner. Either document shall contain the following information: 1. The beneficiary's name, address and Medicaid eligibility identification number; and 2. A description of the specific supplies and/or equipment prescribed; i. For example, the phrase "wheelchair" or "patient needs wheelchair" is insufficient. The order shall describe the type and style of the wheelchair. 3. The length of time the medical equipment items or supplies are required; 4. A diagnosis and summary of the patient's physical condition to support the need for the item(s) prescribed; and 5. The prescriber's name, address and signature. (b) Other information in addition to (a) above may be required for specific items and services, and is described in other sections of this chapter which are related to coverage of the specific item or service. (c) The documentation required in (a) and (b) above shall be maintained on file for a minimum of five years from the date the service was rendered. 10:59-1.6 Prior authorization (PA) (a) Prior authorizations issued by the Medicaid program are intended to reflect decisions regarding medical necessity and purchase/rental options. The issuance of prior authorization is not a guarantee of Medicaid payment. Payment is determined based on the satisfaction of all applicable claims processing edits established by the Division of Medical assistance and Health Services. Payment is made, based on the


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satisfaction of the conditions of this chapter. (b) When a procedure code requires PA, the provider shall first obtain authorization from the appropriate Medicaid District Office (MDO). (See a list of MDOs at N.J.A.C. 10:49, Appendix Form #17.) The Division will provide written notification of the disposition of the PA request. 1. An exception is provided for orthopedic footwear not attached to a bar or brace. In these situations, the PA shall be submitted to the Podiatric Consultant in the Medicaid Central Office (See N.J.A.C. 10:57). 2. Urgent requests may be made by telephone, but the provider shall submit the written PA request within five calendar days (see N.J.A.C. 10:49-6.1). (c) When the purchase price of a DME item is $300.00 or more, prior authorization shall be required for purchase or rental, as described in Appendix A, incorporated herein by reference, except as described in (e) below. (d) When the purchase price for medical supplies is $100.00 or more, prior authorization is required as described in Appendix A, incorporated herein by reference. (e) Certain DME items and medical supplies require prior authorization regardless of purchase price, indicated in Appendix A, incorporated herein by reference. (f) All medical supplies and DME items purchased or rented for use by nursing facility residents require prior authorization. Items included in the NF's per diem are not covered (see N.J.A.C. 10:59-1.4). (g) Medicare/Medicaid claims do not require prior authorization (See N.J.A.C. 10:59-1.9).

CASE NOTES Digital scale for applicant with morbid obesity was not an item for which Medicaid funds were available. R.S. v. Division of Medical Assistance, 95 N.J.A.R.2d (DMA) 65. Medical necessity authorized purchase of thermal scan thermometer with Medicaid funds for severely retarded child. C.F. v. Division of Medical Assistance, 95 N.J.A.R.2d (DMA) 45. 10:59-1.7 Policy considerations for purchase, rental and repair of DME (a) Medical suppliers may request payment for medical supply services only after the supply/equipment has been delivered to the beneficiary (see N.J.A.C. 10:49-9.5). All requests for payment shall be submitted timely, in accordance with N.J.A.C. 10:49-7.2.


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(b) For durable medical equipment requiring prior authorization (PA), decisions regarding rental or purchase rest with the Division of Medical Assistance and Health Services. 1. Durable medical equipment may be rented when, in the judgment of the Medicaid program, the medical need for the equipment is of such a duration that rental of the equipment is more economically practical than authorizing its purchase. (c) When durable medical equipment is authorized and purchased on behalf of a Medicaid beneficiary, ownership of such equipment will vest with the Division of Medical Assistance and Health Services. The beneficiary will be granted a possessory interest for as long as the beneficiary requires use of the equipment. (d) Durable medical equipment items may be repaired and suppliers reimbursed for replacement parts and/or labor charges when, in the judgement of the Medicaid Program, the medical need for the item will continue to exist for a period of time and repair is more economical than purchase. (e) Repair costs related to rented DME shall be the responsibility of the provider and shall be considered a component of the Medicaid rental payment. (f) Reimbursement for repairs, including parts and labor charges, will not be authorized for durable medical equipment under warranty. For purchased DME, reimbursement for the cost of repairs shall be limited to repairs not covered by a manufacturer's warranty. (g) Reimbursement by the Medicaid program shall be limited to services billed by HCPCS codes followed by the appropriate following modifier(s). 1. NU refers to the purchase of medical supplies, new DME and/or services; 2. UE refers to the purchase of used DME; and 3. RR refers to the daily or monthly rental of DME. 10:59-1.8 Basis of reimbursement for medical supplies and DME (a) Payment for purchase of medical supplies or DME shall be based on the following methods: 1. If there is no Medicaid Fee schedule, reimbursement shall be based on the lesser of the provider's usual and customary charge to the general public or a calculated maximum fee allowance equal to 130 percent of a supplier's invoice cost or 80 percent of the manufacturer's price list for supplies and equipment priced by report. i. The invoice shall include the supplier as the addressee, item description, quantity, and cost. ii. The manufacturer's price list shall include a manufacturer's name, item description, and suggested retail price per unit or package, and a notation by a supplier indicating


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the number of units per package, if not described by a manufacturer. 2. If there is a Medicaid Fee schedule, reimbursement shall be based on the lesser of the provider's usual and customary charge to the general public; or the Medicaid maximum fee allowance assigned by the Division. (b) Payment for rental of DME will be calculated as follows: 1. If a medical equipment item has a maximum fee allowance of $100.00 or less, the monthly rental payment will be the amount billed or 20 percent of the approved purchase price, whichever is less. Six such payments shall be deemed to be the full purchase price. No further payments shall be made and the equipment will be considered the property of the State. 2. If a medical equipment item has an approved maximum fee allowance of more than $100.00, the monthly rental payment will be the amount billed or 12 percent of the fee, whichever is less. Ten such payments shall be deemed to be the full purchase price and no further payments shall be made and the equipment will be considered the property of the State. 3. If the purchase of a rental item is authorized prior to the close of the maximum rental period (see N.J.A.C. 10:59-1.8(b)1 and 2), a final payment will be made which equals the difference between the sum of the prior rental payments and the maximum fee allowance. 4. If death, ineligibility, or other circumstances over which the New Jersey Medicaid Program has no control, should occur, rental fees for any medical equipment item shall terminate at the end of the month such circumstance(s) occur and no further payment will be made. (c) Payment for replacement parts and repairs will be made as follows: 1. Reimbursement for replacement parts shall be based on the purchase policy described under N.J.A.C. 10:59-1.8(a); and 2. Reimbursement for labor charges will be the maximum fee allowance established by the Division per hour of labor provided. 10:59-1.9 Dual Medicare/Medicaid or NJ KidCare coverage (a) When a Medicaid or NJ KidCare beneficiary also has Medicare coverage, the Medicaid and the NJ KidCare programs require that Medicare benefits be used first and to the fullest extent. Responsibility for payment by the New Jersey Medicaid or NJ KidCare program shall be limited to the unsatisfied deductible and/or coinsurance to the extent that the combined Medicare/Medicaid or Medicare/NJ KidCare payment does not exceed the Medicaid or NJ KidCare maximum allowable. (b) In those instances where Medicare policy disallows reimbursement for an item/service under certain circumstances, for example, a special wheelchair for a NF resident, the provider shall obtain prior authorization from the Medicaid or NJ KidCare--


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Plan A program and submit a hard copy claim to Medicaid or NJ KidCare--Plan A with an Explanation of Benefits from Medicare attached. (c) Medicare/Medicaid claims shall be filed timely, in accordance with N.J.A.C. 10:49-7.2. (d) When a beneficiary is eligible for Medicare and Medicaid or Medicare and NJ KidCare coverage, a Medicare/Medicaid or Medicare/NJ KidCare claim will cross over from the Medicare DMERC Region A to the Medicaid or NJ KidCare fiscal agent. There are instances, however, where claims will not cross over from Medicare to Medicaid or NJ KidCare, for example, claims denied by Medicare or claims where the Medicaid or NJ KidCare fiscal agent is unable to match pertinent identifying data (see N.J.A.C. 10:49-7.2(d)3 for further instructions). (e) There are situations in which Medicare coverage differs significantly from coverage considered medically necessary by the Medicaid or NJ KidCare program. In these situations, the provider may request PA from the Medicaid or NJ KidCare program prior to requesting Medicare payment. 1. The provider must request PA for the higher level of service under the procedure code assigned by the Division for "reconciliation of downgraded Medicare/Medicaid or Medicare/NJ KidCare claims." (f) For dually eligible beneficiaries, Medicaid or NJ KidCare coverage shall be based on Medicare policy as it relates to rental and/or purchase of supplies and DME except as described in (e) above. 10:59-1.10 Third party liability (TPL), excluding Medicare (a) When a Medicaid beneficiary has other health insurance, the Medicaid program requires that such benefits be used first and to the fullest extent. Supplementation may be made for Medicaid covered services, but the combined total payment shall not exceed the amount payable under the Medicaid program in the absence of other coverage (see N.J.A.C. 10:49-7.3). (b) Regardless of the status of a provider's claim with other third parties, all claims for Medicaid reimbursement shall be received by the Medicaid fiscal agent within the time frames specified in N.J.A.C.10:49-7.2, Timeliness of claim submission. (c) The Medicaid program has not established any crossover arrangements with any third party insurer. 10:59-1.11 Recycling durable medical equipment


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(a) The New Jersey Medicaid and NJ KidCare programs shall utilize the services of a durable medical equipment (DME) recycling contractor, acting as an agent of the State, to recycle certain DME for reuse by Medicaid and NJ KidCare fee-for-service beneficiaries when such equipment is considered medically necessary. (b) The New Jersey Medicaid and NJ KidCare fee-for-service programs shall recycle certain DME when the aggregate cost of recycling an item of DME, including costs for pickup and delivery, repairs, maintenance, tracking of DME and other directly related costs, are less than the Medicaid maximum fee allowance for the purchase of new DME. 1. Coverage and reimbursement for DME which is determined recyclable by the New Jersey Medicaid and NJ KidCare fee-for-service programs shall be limited to such equipment when this equipment is available from the DME recycling contractor. 2. Recyclable DME shall include, but not be limited to, the following: i. Canes, all types; ii. Commodes; iii. Communication devices; iv. Crutches, all types; v. Durable bathroom equipment; vi. Hospital beds, all types; vii. Walkers, all types; viii. Wheelchairs and wheelchair components. (c) Prior to dispensing equipment determined recyclable by the State, medical suppliers shall contact the DME recycling contractor to determine the availability of recycled equipment for reuse. Reimbursement for recycling used equipment shall be limited to services provided by the recycling contractor. (d) Claims for new DME, when such DME is readily available from the DME recycling contractor, shall be denied reimbursement by the Medicaid and NJ KidCare fee-for-service programs. (e) Medical suppliers in receipt of used DME which is considered recyclable by the Medicaid and NJ KidCare programs shall arrange for the return of such equipment to the DME recycling contractor by contacting the contractor directly. 10:59-1.12 Parenteral therapy (a) Parenteral therapy refers to the administration of a drug by the intravenous or subcutaneous route of administration. (b) Total parenteral nutrition (TPN) means the administration of a patient's total daily nutritional needs via the parenteral route of administration.


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(c) All parenteral therapy services, including total parenteral nutrition (TPN), require prior authorization (see N.J.A.C. 10:59-1.6). (d) For parenteral therapy other than TPN, coverage through the medical supplier shall be limited to supplies and equipment. Medicaid and NJ KidCare fee-for-service maximum fee allowances for drug costs related to TPN solutions shall only be reimbursed to medical suppliers who are also licensed as providers of pharmaceutical services. 1. Coverage for all medical supplies and DME related to TPN therapy shall be based on monthly fee allowances as established by the Division (see N.J.A.C. 10:59-2.3 for monthly fee allowances and unit descriptions). (e) All drugs related to parenteral therapy shall be covered as pharmaceutical services (see N.J.A.C. 10:51-1.11) and shall only be billed to the Division by providers of pharmaceutical services (see N.J.A.C. 10:51-1.2(d)). 1. Reimbursement of all DME base solutions and supplies related to parenteral therapy shall be based on the mode of parenteral administration. 2. Medicaid and NJ KidCare fee-for-service maximum fee allowances for parenteral therapy-related DME shall be based on all-inclusive per diem rates established by the Division (see N.J.A.C. 10:59-2.3 for daily allowances and unit descriptions). The per diem rate includes the cost of the base solution. (f) When the beneficiary is a nursing facility resident, all parenteral therapy drugs and TPN solutions shall be billed by the Medicaid or NJ KidCare pharmacy provider that is under contract with the nursing facility to provide pharmaceutical services. 1. The contracted provider of pharmaceutical services must be licensed to provide parenteral therapy (see N.J.A.C. 10:51-1.2(d)) and approved as a medical supplier by the Division (see N.J.A.C. 10:59-1.3). 2. All costs for supplies and DME which are used for the administration of parenteral therapy and TPN solutions, shall be components of the nursing facility per diem rate and shall not be eligible for fee-for-service reimbursement from the New Jersey Medicaid or NJ KidCare programs. 10:59-1.13 Augmentative/alternative communication system (ACS) (a) ACS requires prior authorization. Requests for prior authorization shall include the following: 1. A list of specialists involved in the multi-disciplinary team evaluation of the beneficiary, including, at a minimum, a speech-language pathologist, physical therapist, occupational therapist, and social worker. 2. An evaluation report by the speech-language pathologist, which shall include the following:


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i. The communication status of the beneficiary, including relevant mental and physical disabilities; ii. A list of augmentative/alternative communication devices/systems tried during the evaluation period; iii. The rationale for the selection of the prescribed device/system and a description of how it will enhance functional communicative abilities; iv. A certification that the beneficiary can mentally and physically benefit from the device/system and is willing to use it; v. Recommendations for follow-up instruction so that maximum benefit may be obtained; vi. A description of the beneficiary's gross and fine motor abilities, perceptual skills, reading skills, and cognitive abilities; vii. Results of an audiometric screening and/or audiologic evaluation, as appropriate; viii. A summary of past speech-language treatment; ix. Results of the trial period with the device; and x. A list of recommended augmentative communication devices, including all necessary accessories, prices and provider information. (b) Follow up visits will be made by the appropriate MDO staff, at their discretion, to monitor appropriate ACS use. (c) Reimbursement can be made for ACS rental during the trial period in accordance with the policy contained at N.J.A.C. 10:59-1.7 regarding rental of DME. 10:59-1.14 Pressure reduction systems (a) Pressure reduction systems include: 1. Air fluidized bed systems which employ the circulation of filtered air through silicone-coated ceramic beads creating the characteristics of fluid; 2. Powered low air loss bed systems which incorporate the use of an air- bladder system consisting of a series of interconnected adjustable air sacs designed to allow air escape to reduce support surface pressure. Air to the sacs is supplied by a separate power supply unit; and 3. Low end products which include any powered or non-powered overlay or mattress. (b) Policies for providing and authorizing DME as described in N.J.A.C. 10:59-1.5 and 1.6 apply. (c) Reimbursement for low end products is included in the NF's per diem, and therefore shall not be covered. (d) Periods of Prior Authorization (PA) for air-fluidized and powered low air loss bed systems shall be limited to 30 days.


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(e) Requests for PA for air fluidized and low air loss bed systems shall include the following: 1. A medical history relating to the wound which includes previous therapy and pressure relief systems utilized and found unsuccessful; 2. Physician progress notes indicating medical necessity, plan of treatment, and evaluation of response to treatment specific to the care of the wound; 3. A wound care flow sheet documenting weekly the site, size, depth and stage of the wound, noting also the presence and description of drainage or odor; 4. Laboratory values include a complete blood count and blood chemistries initially and on request thereafter; 5. A nutritional assessment by a registered dietitian initially and on request thereafter; and 6. Photographs of the site, upon permission of the beneficiary/family, after full due consideration is afforded to the beneficiary's right to privacy, dignity and confidentiality. (f) Coverage for air fluidized and low air loss bed systems shall be limited to the following conditions: 1. The beneficiary has two stage III (full-thickness tissue loss) pressure sores or a stage IV (deep tissue destruction) pressure sore which involves two of the following sites: hips, buttocks, or sacrum; and 2. The beneficiary is bedridden or chairbound as a result of severely limited mobility; and 3. The beneficiary is receiving maximal medical/nursing care, previously instituted conservative treatment has been unsuccessful and all other alternative equipment has been considered and ruled out. 4. If the beneficiary has coexisting risk factors (such as vascular irregularities, nutritional depletion, diabetes or immune suppression), they must present post-operatively with a posterior or lateral flap or graft site requiring short-term therapy until the operative site is viable. (g) Coverage for conditions other than those described in (e) above may be considered on an individual basis by the MDO. 10:59-1.15 Apnea monitor (a) Apnea monitors shall require prior authorization (PA) for initial certification and subsequent recertification. 1. To obtain authorization, providers shall complete the "Home Apnea Monitor Certification" form FD-287 which requires the prescriber's signature. The FD- 287 may be used in lieu of a prescription by suppliers. (b) Coverage of apnea monitors shall be limited to use by infants not otherwise


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monitored for the same purpose by another device. (c) Reimbursement for apnea monitors is included in the NF's per diem, and shall not be covered separately. (d) Suppliers shall provide a properly functioning monitor in an environment that assures its safe and effective use. (e) Apnea monitors shall be reimbursed on a monthly rental basis. The rental payment shall include, but not be limited to, belt lead wires, electrodes, patient connecting cable, and battery, if appropriate.

END OF SUBCHAPTER 1


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SUBCHAPTER 2. HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS) 10:59-2.1 Introduction (a) The New Jersey Medicaid Program utilizes the Health Care Financing Administration's (HCFA) Common Procedure Coding System (HCPCS). HCPCS follows the American Medical Association's Physicians' Current Procedural Terminology-- 4th Edition (CPT-4) architecture, employing a five-position code and as many as two 2-position modifiers. Unlike the CPT-4 numeric design, the HCFA assigned codes and modifiers contain alphabetic characters. HCPCS was developed as a three-level coding system. Level I codes are not applicable to medical supplies and durable medical equipment. The level II and Level III codes are as follows: 1. LEVEL II CODES (Narratives found at N.J.A.C. 10:59-2.3) are assigned by Health Care Financing Administration (HCFA) for physician and non-physician services which are not in CPT-4. 2. LEVEL III CODES (Narratives found in N.J.A.C. 10:59-2.3) are assigned by the Division to be used for those services not identified by CPT-4 codes or HCFA-assigned codes. Level III codes identify services unique to New Jersey. (b) The responsibilities of the provider of durable medical equipment (DME) and medical supply services for rendering services and requesting reimbursement are listed at N.J.A.C. 10:59-1. 10:59-2.2 Elements of HCPCS Coding System which require the attention of the provider (a) The list of HCPCS procedure codes in N.J.A.C. 10:55-2.4 is arranged in tabular form with specific information for each code given under columns with the titles "HCPCS Code", "Description", and "Maximum Fee Allowance". (b) The column titled "Maximum Fee Allowance" indicates the maximum amount of reimbursement or the following symbol: 1. "B.R." (By Report) is listed instead of a dollar amount. It means that additional information will be required in order to properly evaluate the service. Attach a copy of the provider's invoice or manufacturer's price list to the claim form. (c) Services and procedures may be modified under certain circumstances. When applicable, the modifying circumstances should be identified by the addition of alphabetic and/or numeric characters at the end of the HCPCS procedure code. The New Jersey Medicaid program's recognized modifier codes for medical supply services are as follows: 1. "NU" Purchase of new Durable Medical Equipment (DME)

2. "UE" Purchase of used DME 3. "RR" DME rental service


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10:59-2.3 HCPCS procedure codes and maximum fee allowance schedule for medical supplies and durable medical equipment Maximum HCPCS Fee Code Description Allowance A4206 Syringe with needle, sterile 1cc B.R. A4207 Syringe with needle, sterile 2cc B.R. A4208 Syringe with needle, sterile 3cc B.R.

A4209 Syringe with needle, sterile 5cc or greater B.R. A4211 Supplies for self-administered injections B.R. A4212 Huber-type needle, each B.R. A4213 Syringe, sterile, 20cc or greater B.R. A4214 Sterile saline or water, 30 cc vial 0.81/vial A4215 Needles only, sterile, any size B.R. A4230 Infusion set for external insulin pump, non-needle, cannula B.R. type A4231 Infusion set for external insulin pump, needle type B.R. A4232 Syringe with needle for external insulin pump, sterile 3 cc B.R. A4244 Alcohol or peroxide, per pint B.R. A4245 Alcohol wipes, per box B.R. A4246 Betadine or Phisohex solution, per pint B.R. A4247 Betadine or iodine swabs/wipes, per box B.R. A4250 Urine test or reagent strips or tablets B.R. (100 tablets or strips) A4253 Blood glucose test or reagent strips B.R. for home blood glucomitor, per 50 strips A4256 Normal, low and high calibrator solution/chips B.R. A4258 Spring powered device for lancet, each B.R. A4259 Lancets, per box B.R. A4265 Paraffin B.R. A4300 Implantable vascular access portal/catheter B.R. (venous, arterial, epidural or peritoneal) A4305 Disposable drug delivery system, flow rate B.R. of 50 ml or greater per hour A4306 Disposable drug delivery system, flow rate B.R. of 5 ml or less per hour A4310 Insertion tray without drainage bag and 6.61 without catheter (accessories only) A4311 Insertion tray without drainage bag with 8.34 indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.)


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A4312 Insertion tray without drainage bag with 8.34 indwelling catheter, foley type, two-way, all silicone A4313 Insertion tray without drainage bag with 8.34 indwelling catheter, foley type, three-way, for continuous irrigation A4314 Insertion tray with drainage bag with 15.46 indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.) A4315 Insertion tray with drainage bag with 15.46 indwelling catheter, foley type, two-way, all silicone A4316 Insertion tray with drainage bag with 15.46 indwelling catheter, foley type, three-way, for continuous irrigation A4320 Irrigation tray for bladder irrigation 5.00 with bulb or piston syringe A4322 Irrigation syringe, bulb or piston 2.50 A4323 Sterile saline irrigation solution, 1000 ml. 8.00 A4326 Male external catheter; specialty type B.R. (for example, inflatable or faceplate, each) A4327 Female external urinary collection device; B.R. metal cup, each A4328 Female external urinary collection device; 10.00 pouch A4329 External catheter starter set, male/female, 39.95 includes catheters/urinary collection device, bag/pouch and accessories (tubing, clamps, etc.), 7 day supply A4330 Perianal fecal collection pouch with adhesive B.R. A4335 Incontinence supply; miscellaneous B.R. A4338 Indwelling catheter; foley type, two-way latex 8.14 with coating (such as teflon, silicone, silicone elastomer, or hydrophilic) A4340 Indwelling catheter; specialty type, 10.00 (such as coude, mushroom or wing) A4344 Indwelling catheter, foley type, two-way, 15.52 all silicone A4346 Indwelling catheter, foley type, three-way 15.00 for continuous irrigation A4347 Male external catheter with or without 7.29


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adhesive, with or without anti-reflux device; per dozen A4351 Intermittent urinary catheter; straight tip 5.00 A4352 Intermittent urinary catheter; coude 5.00 (curved) tip A4354 Insertion tray with drainage bag, 9.00 without catheter A4355 Irrigation tubing set for continuous bladder 6.86 irrigation through a three-way indwelling foley catheter A4356 External urethral clamp or compression 37.03 device (not to be used for catheter clamp) A4357 Bedside drainage bag, day or night, 7.94 with or without anti-reflux device, with or without tube A4358 Urinary leg bag; vinyl, with or without 7.12 tube A4359 Urinary suspensory without leg bag 27.00 A4361 Ostomy face plate 6.20 A4362 Skin barrier; solid, 4" x 4" or equivalent; 5.03 each A4363 Skin barrier; liquid (spray, brush, etc.) 4.07 powder or paste; per oz. A4364 Adhesive for ostomy or catheter; liquid 4.58 (for example, spray or brush) cement, powder or paste; any composition (for example, silicone, latex); per oz. A4367 Ostomy belt 6.86 A4397 Irrigation supplies; sleeve 4.50 A4398 Irrigation supplies; bag 2.25 A4399 Irrigation supplies; cone/catheter 11.25 A4400 Ostomy irrigation set 24.61 A4402 Lubricant 1.08 A4404 Ostomy rings 1.22 A4421 Not otherwise classified ostomy supplies; B.R. ureterostomy supplies A4454 Tape, all types, all sizes B.R. A4455 Adhesive remover or solvent (for tape, B.R. cement or other adhesive) A4460 Elastic bandage, per roll (for example, B.R. compression bandage) A4465 Nonelastic binder for extremity B.R.


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A4470 Gravlee jet washer B.R. A4480 Vabra aspirator B.R. A4550 Surgical trays B.R. A4554 Disposable underpads, all sizes (for example, 0.31 Chux's), each A4556 Electrodes (for example, apnea monitor) B.R. A4557 Lead wires (for example, apnea monitor) B.R. A4558 Conductive paste or gel B.R. A4560 Pessary 20.94 A4565 Slings B.R. A4570 Splint B.R. A4572 Rib belt B.R. A4575 Topical hyperbaric oxygen chamber, disposable B.R. A4581 Supplies, Risser jacket B.R. A4595 TENS supplies, 2 lead, per month B.R. A4611 Battery, heavy duty; replacement for 180.00 patient-owned ventilator A4612 Battery cables; replacement for 44.00 patient-owned ventilator A4613 Battery charger; replacement for B.R. patient-owned ventilator A4614 Peak expiratory flow rate meter, hand held B.R. A4615 Cannula, nasal 7.50 A4616 Tubing (oxygen), per foot B.R. A4617 Mouthpiece 5.00 A4618 Breathing circuits 9.15 A4619 Face tent 10.00 A4620 Variable concentration mask 10.00 A4621 Tracheostomy mask or collar 10.17 A4622 Tracheostomy or laryngectomy tube 75.00 A4623 Tracheostomy, inner cannula 6.00 (replacement only) A4624 Tracheal suction catheter, any type, 2.00 each A4625 Tracheostomy care or cleaning starter 8.00 kit A4626 Tracheostomy cleaning brush, each 3.00 A4627 Spacer, bag or reservoir, with or B.R. without mask, for use with metered dose inhaler A4628 Oropharyngeal suction catheter, each B.R. A4629 Tracheostomy care kit for established tracheostomy B.R.


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A4630 Replacement batteries for medically B.R. necessary TENS, owned by patient A4631 Replacement batteries for medically B.R. necessary electronic wheelchair, owned by patient A4635 Underarm pad, crutch, replacement, each B.R. A4636 Replacement handgrip, cane, crutch, B.R. walker, each A4637 Replacement tip, cane crutch, walker, B.R. each A4640 Replacement pad for use with medically B.R. necessary alternating pressure pad, owned by patient A4649 Surgical supplies; miscellaneous B.R. A4655 Needles and syringes for dialysis B.R. A4660 Sphygmomanometer/blood pressure apparatus B.R. with cuff and stethoscope A4663 Blood pressure cuff, only B.R. A4670 Automatic blood pressure monitor B.R. A4700 Standard dialysate solution, each B.R. A4705 Bicarbonate dialysate solution, each B.R. A4712 Water, sterile B.R. A4714 Treated water (deionized, distilled, B.R. reverse osmosis) for use in dialysis system A4730 Fistula cannulation set for dialysis B.R. only A4735 Local/topical anesthetics for dialysis B.R. only A4740 Shunt accessories for dialysis only B.R. A4750 Blood tubing, arterial or venous, each B.R. A4755 Blood tubing, arterial and venous combined B.R. A4760 Dialysate standard testing solution, supplies B.R. A4765 Dialysate concentrate additives, each B.R. A4770 Blood testing supplies (for example, vacutainers B.R. and tubes) A4771 Serum clotting time tube, per box B.R. A4772 Dextrostick or glucose test strips, B.R. per box A4773 Hemostix, per bottle B.R. A4774 Ammonia test paper, per box B.R. A4780 Sterilizing agent for dialysis B.R.


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equipment, per gallon A4820 Hemodialysis kit supplies B.R. A4850 Hemostats with rubber tips for dialysis B.R. A4860 Disposable catheter caps B.R. A4900 C.A.P.D. (continuous ambulatory peritoneal 1,600.00 dialysis), inclusive of all necessary supplies--per month A4901 C.C.P.D. (continuous cycling peritoneal 2,000.00 dialysis), inclusive of all necessary supplies, including the auto-peritoneal dialysis cycler--per month A4905 Intermittent peritoneal dialysis (IPD) B.R. supply kit A4912 Gomco drain bottle B.R. A4913 Miscellaneous dialysis supplies, not B.R. identified elsewhere A4914 Preparation kits B.R. A4918 Venous pressure clamps, each B.R. A4919 Dialyzer holder, each B.R. A4920 Harvard pressure clamp, each B.R. A4921 Measuring cylinder, any size, each B.R. A5051 Pouch, closed; with barrier attached 3.05 (1 piece) A5052 Pouch, closed; without barrier attached 3.05 (1 piece) A5053 Pouch, closed; for use on faceplate 3.05 A5054 Pouch, closed; for use on barrier with 3.05 flange (2 piece) A5055 Stoma cap 2.00 A5061 Pouch, drainable; with barrier attached 4.07 (1 piece) A5062 Pouch, drainable; without barrier attached 4.07 (1 piece) A5063 Pouch, drainable; for use on barrier with 4.07 flange (2 piece system) A5064 Pouch, drainable; with faceplate attached; 4.07 plastic or rubber A5065 Pouch, drainable; for use on faceplate; 4.07 plastic or rubber A5071 Pouch, urinary; with barrier attached 4.07 (1 piece) A5072 Pouch, urinary; without barrier attached 4.07


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(1 piece) A5073 Pouch, urinary; for use on barrier with 4.07 flange (2 piece system) A5074 Pouch, urinary; with faceplate attached; 4.07 plastic or rubber A5075 Pouch urinary; for use with faceplate; 4.07 plastic or rubber A5081 Continent device; plug for continent 3.50 stoma A5082 Continent device; catheter for continent 11.00 stoma A5093 Ostomy accessory; convex insert 1.65 A5102 Bedside drainage bottle, rigid or expandable 28.00 A5105 Urinary suspensory; with leg bag, with or 31.90 without tube A5112 Urinary leg bag; latex 7.12 A5113 Leg strap; latex, per set 4.00 A5114 Leg strap; foam or fabric, per set 8.95 A5119 Skin barrier; wipes, box per 50 9.50 A5121 Skin barrier; solid, 6' x 6' or equivalent, 5.03 each A5122 Skin barrier; solid, 8' x 8' or equivalent, 5.03 each A5123 Skin barrier; with flange (solid, flexible 6.00 or accordion), any size, each A5126 Adhesive; disc or foam pad .25 A5131 Appliance cleaner, incontinence and ostomy 16.25 appliances, 16 oz. A5200 Percutaneous catheter/tube anchoring device, adhesive skin B.R. attachment A6020 Collagen-based wound dressing, wound cover, each dressing B.R. A6154 Wound pouch, each B.R. A6196 Alginate dressing, wound cover, pad size 16 sq. in. or less, B.R. each A6197 Alginate dressing, wound cover, pad size more than 16 but B.R. less than or equal to 48 sq. in., each dressing A6198 Alginate dressing, wound cover, pad size more than 48 sq. B.R. in., each dressing A6199 Alginate dressing, wound filler, per 6 inches B.R. A6200 Composite dressing, pad size 16 sq. in. or less, without B.R. adhesive border, each dressing A6201 Composite dressing, pad size more than 16 sq. in., but less B.R.


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than or equal to 48 sq. in., without adhesive border, each dressing A6202 Composite dressing, pad size more than 48 sq. in., without B.R. adhesive border, each dressing A6203 Composite dressing, pad size 16 sq. in. or less with any size B.R. adhesive border, each dressing A6204 Composite dressing, pad size more than 16 but less than or B.R. equal to 48 sq. in., with any size adhesive border, each dressing A6205 Composite dressing, pad size more than 48 sq. in., with any B.R. size adhesive border, each dressing A6206 Contact layer, 16 sq. in. or less, each dressing B.R. A6207 Contact layer, more than 16 but less than or equal to 48 sq. B.R. in., each dressing A6208 Contact layer, more than 48 sq. in., each dressing B.R. A6209 Foam dressing, wound cover, pad size 16 sq. in., or less, B.R. without adhesive border, each dressing A6210 Foam dressing, wound cover, pad size more than 16 but less B.R. than or equal to 48 sq. in., without adhesive border, each dressing A6211 Foam dressing, wound cover, pad size more than 48 sq. in., B.R. without adhesive border, each dressing A6212 Foam dressing, wound cover, pad size 16 sq. in. less, with B.R. any size adhesive border, each dressing A6213 Foam dressing, wound cover, pad size more than 16 but less B.R. than or equal to 48 sq. in. with any size adhesive border, each A6214 Foam dressing, wound cover, pad size more than 48 sq. in., B.R. with any size adhesive border, each dressing A6215 Foam dressing, wound filler, per gram B.R. A6216 Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or B.R. less, without adhesive border, each dressing A6217 Gauze, non-impregnated, non-sterile, pad size more than 16 B.R. but less than or equal to 48 sq. in., without adhesive border, each dressing A6218 Gauze, non-impregnated, non-sterile, pad size more than 48 B.R. sq. in., without adhesive border, each dressing A6219 Gauze, non-impregnated, pad size 16 sq. in. or less, with any B.R. size adhesive border, each dressing A6220 Gauze, non-impregnated, pad size more than 16 but less than B.R. or equal to 48 sq. in., with any size adhesive border, each dressing


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A6221 Gauze, non-impregnated, pad size more than 48 sq. in., with B.R. any size adhesive border, each dressing A6222 Gauze, impregnated, other than water or normal saline, pad B.R. size 16 sq. in. or less, without adhesive border, each dressing A6223 Gauze, impregnated, other than water or normal saline, pad B.R. size more than 16 but less than or equal to 48 sq. in., without adhesive border, each dressing A6224 Gauze, impregnated, other than water or normal saline, pad B.R. size more than 48 sq. in., without adhesive border, each dressing A6228 Gauze, impregnated, water or normal saline, pad size 16 sq. B.R. in. or less, without adhesive border, each dressing A6229 Gauze, impregnated, water or normal saline, pad size more B.R. than 16 but less than or equal to 48 sq. in., without adhesive border, each dressing A6230 Gauze, impregnated, water or normal saline, pad size more B.R. than 48 sq. in., without adhesive border, each dressing A6234 Hydrocolloid dressing, wound cover, pad size 16 sq. in. or B.R. less, without adhesive border, each dressing A6235 Hydrocolloid dressing, wound cover, pad size more than 16 but B.R. less than or equal to 48 sq. in., without adhesive border, each dressing A6236 Hydrocolloid dressing, wound cover, pad size more than 48 sq. B.R. in., without adhesive border, each dressing A6237 Hydrocolloid dressing, wound cover, pad size 16 sq. in. or B.R. less, with any size adhesive border, each dressing A6238 Hydrocolloid dressing, wound cover, pad size more than 16 but B.R. less than or equal to 48 sq. in., with any size adhesive border, each dressing A6239 Hydrocolloid dressing, wound cover, pad size more than 48 sq. B.R. in., with any size adhesive border, each dressing A6240 Hydrocolloid dressing, wound filler, paste, per fluid ounce B.R. A6241 Hydrocolloid dressing, wound filler, dry form, per gram B.R. A6242 Hydrogel dressing, wound cover, pad size 16 sq. in. or less, B.R. without adhesive border, each dressing A6243 Hydrogel dressing, wound cover, pad size more than 16 but B.R. less than or equal to 48 sq. in., without adhesive border, each dressing A6244 Hydrogel dressing, wound cover, pad size more than 48 sq. B.R. in., without adhesive border, each dressing A6245 Hydrogel dressing, wound cover, pad size 16 sq. in. or less, B.R.


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with any size adhesive border, each dressing A6246 Hydrogel dressing, wound cover, pad size more than 16 but B.R. less than or equal to 48 sq. in., with any size adhesive border, each dressing A6247 Hydrogel dressing, wound cover, pad size more than 48 sq. B.R. in., with any size adhesive border, each dressing A6248 Hydrogel dressing, wound filler, gel, per fluid ounce B.R. A6249 Hydrogel dressing, wound filler, dry form, per gram B.R. A6250 Skin sealants, protectants, moisturizers any type, any size B.R. A6251 Specialty absorptive dressing, wound cover, pad size 16 sq. B.R. in. or less, without adhesive border, each dressing A6252 Specialty absorptive dressing, wound cover, pad size more B.R. than 16 but less than or equal to 48 sq. in., without adhesive border, each dressing A6253 Specialty absorptive dressing, wound cover, pad size more B.R. than 48 sq. in., without adhesive border, each dressing A6254 Specialty absorptive dressing, wound cover, pad size 16 sq. B.R. in. or less, any size adhesive border, each dressing A6255 Specialty absorptive dressing, wound cover, pad size more B.R. than 16 but less than or equal to 48 sq. in., with any size adhesive border, each dressing A6256 Specialty absorptive dressing, wound cover, pad size more B.R. than 48 sq. in., with any size adhesive border, each dressing A6257 Transparent film, 16 sq. in. or less, each dressing B.R. A6258 Transparent film, more than 16 but less than or equal to 48 B.R. sq. in., each dressing A6259 Transparent film, more than 48 sq. in., each dressing B.R. A6260 Wound cleansers, any type, any size B.R. A6261 Wound filler, not elsewhere classified, gel/paste, per fluid B.R. ounce A6262 Wound filler, not elsewhere classified, dry form, per gram B.R. A6263 Gauze, elastic, non-sterile, all types, per linear yard B.R. A6264 Gauze, non-elastic, non-sterile, per linear yard B.R. A6265 Tape, all types, per 18 square inches B.R. A6266 Gauze, impregnated, other than water or normal saline, any B.R. width, per linear yard A6402 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, B.R. without adhesive border, each dressing A6403 Gauze, non-impregnated, sterile, pad size more than 16 but B.R. less than or equal to 48 sq. in., without adhesive border, each dressing


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A6404 Gauze, non-impregnated, sterile, pad size more than 48 sq. B.R. in., without adhesive border, each dressing A6405 Gauze, elastic, sterile, all types, per linear yard B.R. A6406 Gauze, non-elastic, sterile, per linear yard B.R. B4034 Enteral feeding supply kit; syringe 150.00 (monthly) B4035 Enteral feeding supply kit; pump fed 275.00 (monthly) B4036 Enteral feeding supply kit; gravity fed 195.00 (monthly) B4081 Nasogastric tubing with stylet 16.75 B4082 Nasogastric tubing without stylet 12.98 B4083 Stomach tube--Levine type 1.90 B4084 Gastrostomy/jejunostomy tubing 15.00 B4085 Gastrostomy tube, silicone with sliding ring, each B.R. B4150 Enteral formulae; category I: B.R. Semi-synthetic intact protein/protein isolates (for example, Enrich, Ensure, Ensure HN, Ensure Powder, Isocal, Lonalac Powder, Meritene, Meritene Powder, Osmolite, Osmolite HN, Portagen Powder, Sustacal, Renu, Sustagen Powder, Travasorb) 1 package = 1 unit B4151 Enteral formulae; category I: Natural B.R. intact protein/protein isolates (for example, Compleat B, Vitaneed, Compleat B Modified) 1 package = 1 unit B4152 Enteral formulae; category II: Intact B.R. protein/protein isolates (calorically dense) (for example, Magnacal, Isocal HCN, Sustacal HC, Ensure Plus, Ensure Plus HN) 1 package = 1 unit B4153 Enteral formulae; category III: hydrolyzed B.R protein/amino acids (e.g., Criticare HN, Vivonex T.E.N. (Total Enteral Nutrition), Vivonex HN, Precision HN, Precision Isotonic) 1 package = 1 unit B4156 Enteral formulae; category VI: standardized B.R. nutrients (Vivonex STD, Precision LR and Tolerex) 1 package = 1 unit B4164 Parenteral nutrition solution: 13.26


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carbohydrates (dextrose), 50% or less (500 ml = 1 unit)--home mix B4168 Parenteral nutrition solution; amino 18.59 acid, 3.5%, (500 ml = 1 unit) --home mix B4172 Parenteral nutrition solution; amino 30.50 acid 5.5% through 7% (500 ml = 1 unit)-- home mix B4176 Parenteral nutrition solution; amino 43.22 acid, 7% through 8.5% (500 ml = 1 unit)--home mix B4178 Parenteral nutrition solution; amino 43.22 acid, greater than 8.5% (500 ml = 1 unit) B4180 Parenteral nutrition solution; 18.30 carbohydrates, (dextrose), greater than 50% (500 ml = 1 unit)--home mix B4184 Parenteral nutrition solution; lipids, 10% 60.00 with administration set (500 ml = 1 unit) (12 per month) B4186 Parenteral nutrition solution, lipids, 20% 80.00 with administration set (500 ml = 1 unit) (12 per month) B4189 Parenteral nutrition solution; compounded 133.50 amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 10 to 51 grams of protein--premix B4193 Parenteral nutrition solution; compounded 172.50 amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein--premix B4197 Parenteral nutrition solution; compounded 210.00 amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein--premix B4199 Parenteral nutrition solution; compounded 252.69 amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein--premix


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B4216 Parenteral nutrition; additives (vitamins, 11.65 trace elements, heparin, electrolytes)-- (per day) home mix B4220 Parenteral nutrition supply kit for 1 month--premix 182.98 B4222 Parenteral nutrition supply kit for one month-- 283.25 home mix B4224 Parenteral nutrition administration kit 600.00 for 1 month B5000 Parenteral nutrition solution; compounded 9.28 amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal--Amirosyn RF, NephrAmine, RenAmin --premix B5100 Parenteral nutrition solution; compounded 3.63 amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic-- FreAmine HBC, HepatAmine--premix B5200 Parenteral nutrition solution; compounded 4.94 amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-- branch chain amino acids--premix B9000 Enteral nutrition infusion pump--without 950.00 alarm B9002 Enteral nutrition infusion pump--with 950.00 alarm B9004 Parenteral nutrition infusion pump, $227.40 per month portable B9006 Parenteral nutrition infusion pump, $227.40 per month stationary B9998 Not otherwise classified (NOC) for B.R. enteral supplies E0100 Cane, includes canes of all materials, 14.97 adjustable or fixed with tips E0105 Cane, quad or three prong, includes canes 39.48 of all materials, adjustable or fixed


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with tips E0110 Crutches forearm, includes crutches of various materials, 65.43 adjusted or fixed, complete with tips and handgrips, pair E0111 Crutch forearm, includes crutches of various materials, 57.92 adjustable or fixed, with tip and handgrip, each E0112 Crutches underarm, wood, adjustable or 47.46 fixed, with pads, tips and handgrips, pair E0113 Crutch underarm, wood, adjustable or fixed, 19.51 with pad, tip and handgrip, each E0114 Crutches underarm, aluminum, adjustable or 68.56 fixed, with pads, tips and handgrips, pair E0116 Crutch underarm, aluminum, adjustable or 18.99 fixed, with pad, tip and handgrip, each E0130 Walker, rigid (pickup), adjustable or 55.94 fixed height E0135 Walker, folding (pickup), adjustable or 59.43 fixed height E0141 Walker, wheeled, without seat 95.86 E0142 Rigid walker, wheeled, with seat 343.81 E0143 Folding walker, wheeled, without seat 109.05 E0145 Walker, wheeled, with seat and crutch 176.60 attachments E0146 Walker, wheeled, with seat 318.23 E0147 Heavy duty, multiple breaking system, 206.71 variable wheel resistance walker E0153 Platform attachment, forearm crutch, 55.37 each E0154 Platform attachment, walker, each 68.56 E0155 Wheel attachment, rigid pick-up walker 25.62 E0156 Seat attachment, walker 21.09 E0157 Crutch attachment, walker, each 55.37 E0158 Leg extensions, walker 33.74 E0160 Sitz type bath, portable, fits 9.50 over commode seat E0161 Sitz type bath, portable, fits 52.73 over commode seat, with faucet attachments E0162 Sitz bath, chair B.R. E0163 Commode chair, stationary, with 89.16 fixed arms E0164 Commode chair, mobile, with fixed 210.93 arms


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E0165 Commode chair, stationary, with 181.01 detachable arms E0166 Commode chair, mobile, with detachable 265.35 arms E0167 Pail or pan for use with commode chair 10.19 E0175 Foot rest, for use with commode chair, 44.07 each E0176 Air pressure pad or cushion, non- B.R. positioning E0177 Water pressure pad or cushion, non- B.R. positioning E0178 Gel pressure pad or cushion, non- B.R. positioning E0179 Dry pressure pad or cushion, non- B.R. positioning E0180 Pressure pad, alternating with pump 240.44 E0181 Pressure pad, alternating with pump, heavy duty 263.73 E0182 Pump for alternating pressure pad 291.08 E0184 Dry pressure mattress 68.56 E0185 Gel pressure pad for mattress 62.22 E0186 Air pressure mattress B.R. E0187 Water pressure mattress B.R. E0188 Synthetic sheepskin pad 21.09 E0189 Lambswool sheepskin pad, any size 21.09 E0191 Heel or elbow protector, each 10.34 E0192 Low pressure and positioning 326.66 equalization pad E0193 Powered air flotation bed (low air 36.00 loss therapy) (per day) E0194 Air fluidized bed 65.20 (per day) E0200 Heat lamp, without stand (table model), 36.92 includes bulb, or infrared element E0202 Phototherapy (bilirubin) light with B.R. photometer E0235 Paraffin bath unit, portable (see medical 194.38 supply code A4265 for paraffin) E0236 Pump for water circulating pad B.R. E0237 Water circulating heat pad with pump B.R. E0241 Bathtub wall rail, each B.R. E0242 Bathtub rail, floor base B.R. E0243 Toilet rail, each B.R.


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E0244 Raised toilet seat B.R. E0245 Tub stool or bench B.R. E0246 Transfer tub rail attachment B.R. E0249 Pad for water circulating heat unit 124.44 E0250 Hospital bed, fixed height, with any 881.42 type side rails, with mattress E0251 Hospital bed, fixed height, with any 672.33 type side rails, without mattress E0255 Hospital bed, variable height, hi-lo, 964.20 with any type side rails, with mattress E0256 Hospital bed, variable height, hi-lo, B.R. with any type side rails, without mattress E0260 Hospital bed, semi-electric (head and 1,542.26 foot adjustments), with any type side rails, with mattress E0261 Hospital bed, semi-electric (head and foot B.R. adjustments), with any type side rails, without mattress E0265 Hospital bed, total electric (head, foot, 1,940.52 and height adjustments), with any type side rails, with mattress E0266 Hospital bed, total electric (head, foot, 1,909.20 and height adjustments), with any type side rails, without mattress E0270 Hospital bed, institutional type includes: B.R. oscillating, circulating and stryker frame, with mattress E0271 Mattress, inner spring 168.73 E0272 Mattress, foam rubber 155.55 E0273 Bed board B.R. E0274 Over-bed table B.R. E0275 Bed pan, standard, metal or plastic 15.82 E0276 Bed pan, fracture, metal or plastic 12.60 E0277 Alternating pressure mattress B.R. E0280 Bed cradle, any type 29.53 E0290 Hospital bed, fixed height, without B.R. side rails, with mattress E0291 Hospital bed, fixed height, without B.R. side rails, without mattress E0292 Hospital bed, variable height, hi-lo, B.R. without side rails, with mattress E0293 Hospital bed, variable height, hi-lo, B.R.


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without side rails, without mattress E0294 Hospital bed, semi-electric (head and B.R. foot adjustments), without side rails, with mattress E0295 Hospital bed, semi-electric (head and B.R. foot adjustments), without side rails, without mattress E0296 Hospital bed, total electric (head, B.R. foot and height adjustments), without side rails, with mattress E0297 Hospital bed, total electric (head, B.R. foot and height adjustments), without side rails, without mattress E0305 Bedside rails, half length 143.77 E0310 Bedside rails, full length 164.74 E0325 Urinal; male, jug-type, any material 6.53 E0326 Urinal; female, jug-type, any material 9.28 E0424 Stationary compressed gaseous oxygen system, rental; includes 250.00 contents (per unit), regulator, flowmeter, humidifier, (per nebulizer, cannula or mask and tubing; 1 unit = 50 cubic month) ft. E0431 Portable gaseous oxygen system, rental; 47.33 includes regulator, flowmeter, humidifier, (per month) cannula or mask, and tubing E0434 Portable liquid oxygen system, rental; includes portable 47.33 container, supply reservoir, humidifier, flowmeter, refill (per adaptor, contents gauge, cannula or mask, and tubing month) E0439 Stationary liquid oxygen system, rental; includes use of 250.00 reservoir, contents (per unit), regulator, flowmeter, (per humidifier, nebulizer, cannula or mask, and tubing; 1 unit month) = 10 lbs. E0441 Oxygen contents, gaseous, per unit (for use 6.50 with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned; 1 unit = 50 cubic ft.) E0442 Oxygen contents, liquid, per unit (for use 14.00 with owned liquid stationary systems or when both a stationary and portable liquid system are owned; l unit = 10 lbs.) E0443 Portable oxygen contents, gaseous, per unit . 65 (for use only with portable gaseous systems


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36

when no stationary gas or liquid system is used; 1 unit = 5 cubic ft.) E0444 Portable oxygen contents, liquid, per unit 1.40 (for use only with portable liquid systems when no stationary gas or liquid system is used; 1 unit = 1 lb.) E0450 Volume ventilator; stationary or portable 10,546.29 E0452 Intermittent assist device with continuous B.R. positive airway pressure device (CPAP) NOTE: Medicaid and NJ KidCare fee-for-service reimbursement, all supplies necessary for the use and maintenance of the device E0453 Therapeutic ventilator; suitable for use B.R. 12 hours or less per day E0455 Oxygen tent, excluding croup or pediatric B.R. tents E0457 Chest shell (cuirass) 414.80 E0459 Chest wrap 539.24 E0460 Negative pressure ventilator; portable B.R. or stationary E0462 Rocking bed with or without rails B.R. E0480 Percussor, electric or pneumatic, 279.47 home model E0500 IPPB machine, all types, with built-in 469.32 nebulization; manual or automatic valves; internal or external power source E0550 Humidifier, durable for extensive 315.33 supplemental humidification during IPPB treatments or oxygen delivery E0555 Humidifier, durable, glass or autoclavable 15.00 plastic bottle type, for use with regulator or flowmeter E0560 Humidifier, durable for supplemental 64.64 humidification during IPPB treatment or oxygen delivery E0565 Compressor, air power source for 506.07 equipment which is not self-contained or cylinder driven E0570 Nebulizer, with compressor 166.19 E0575 Nebulizer, ultrasonic 732.97 E0580 Nebulizer, durable, glass or autoclavable 121.29 plastic, bottle type, for use with regulator or flowmeter


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E0585 Nebulizer, with compressor and heater 121.29 E0600 Suction pump, home model, portable 409.72 E0601 Continuous airway pressure (CPAP) device 126.56 (per month) NOTE: Medicaid and NJ KidCare fee-for-service reimbursement, all supplies necessary for the use and maintenance of the device E0605 Vaporizer, room type 30.58 E0606 Postural drainage board 158.19 E0607 Home blood glucose monitor 90.00 E0608 Apnea monitor 200.00 (per month) E0609 Blood glucose monitor with special features B.R. (for example, voice synthesizers, automatic timers, etc.) E0610 Pacemaker monitor, self-contained (checks 336.42 battery depletion, includes audible and visible check systems) E0615 Pacemaker monitor, self-contained, (checks 336.42 battery depletion and other pacemaker components, includes digital/visible check systems E0621 Sling or seat, patient lift, canvas or nylon 63.36 E0625 Patient lift, Kartop, bathroom or toilet B.R. E0630 Patient lift, hydraulic, with seat or sling 932.66 E0635 Patient lift, electric with seat or sling 770.15 E0650 Pneumatic compressor, nonsegmental home model, 522.05 (lymphedema pump) E0651 Pneumatic compressor, segmental home model, 732.97 (lymphedema pump) without calibrated gradient pressure E0652 Pneumatic compressor, segmental home model, 3,374.81 (lymphedema pump) with calibrated gradient pressure E0655 Nonsegmental pneumatic appliance for use 83.42 with pneumatic compressor, half arm E0660 Nonsegmental pneumatic appliance for use 137.10 with pneumatic compressor, full leg


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38

E0665 Nonsegmental pneumatic appliance for use 89.75 with pneumatic compressor, full arm E0666 Nonsegmental pneumatic appliance for use 131.83 with pneumatic compressor, half leg E0667 Segmental pneumatic appliance for use with 258.39 pneumatic compressor, full leg E0668 Segmental pneumatic appliance for use with 226.75 pneumatic compressor, full arm E0669 Segmental pneumatic appliance for use with B.R. pneumatic compressor, half leg E0670 Segmental pneumatic appliance for use with B.R. pneumatic compressor, half arm E0671 Segmental gradient pressure pneumatic appliance, full leg B.R. E0672 Segmental gradient pressure pneumatic appliance, full arm B.R. E0673 Segmental gradient pressure pneumatic appliance, half leg B.R. E0690 Ultraviolet cabinet, appropriate for home B.R. use safety equipment E0700 Safety equipment (for example, belt, harness or B.R. vest) E0710 Restraints, any type (body, chest, wrist B.R. or ankle) E0720 TENS, two lead, localized stimulation 452.02 E0730 TENS, four lead, larger area/multiple 448.08 nerve stimulation E0731 Form-fitting conductive garment for B.R. delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric) E0740 Incontinence treatment system, pelvic floor stimulator, B.R. monitor, sensor and/or trainer E0744 Neuromuscular stimulator for scoliosis 1,031.82 E0745 Neuromuscular stimulator, electronic 1,049.36 shock unit E0746 Electromyography (EMG), biofeedback 694.79 device E0747 Osteogenesis stimulator (noninvasive) 2,742.04 E0748 Osteogenic stimulator, noninvasive, spinal applications B.R. E0755 Electronic salivary reflex stimulator B.R. (intraoral/noninvasive) E0776 IV pole 69.74 E0781 Ambulatory infusion pump, single or multiple channels with B.R. administrative equipment, worn by patient


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E0784 External ambulatory infusion pump, insulin B.R. E0791 Parenteral infusion pump, stationary, single B.R. or multichannel E0840 Traction frame, attached to headboard, 36.92 simple cervical traction E0850 Traction stand, freestanding, simple 36.92 cervical traction E0860 Traction equipment, overdoor, cervical 27.17 E0870 Traction frame, attached to footboard, 83.84 simple extremity traction (for example, Buck's) E0880 Traction stand, freestanding simple 68.56 extremity traction (for example, Buck's) E0890 Traction frame, attached to footboard, 80.47 simple pelvic traction E0900 Traction stand, freestanding simple 80.47 pelvic traction (for example, Buck's) E0910 Trapeze bars, a/k/a patient helper, 163.74 attached to bed, with grab bar E0920 Fracture frame, attached to bed, 394.43 includes weights E0930 Fracture frame, freestanding, 394.43 includes weights E0935 Passive motion exercise device 17.00 (per day) E0940 Trapeze bar, freestanding, 314.78 complete with grab bar E0941 Gravity assisted traction 384.94 device, any type E0942 Cervical head harness/halter 15.82 E0943 Cervical pillow 41.48 E0944 Pelvic belt/harness/boot 32.74 E0945 Extremity belt/harness 36.92 E0946 Fracture, frame, dual with cross bars, 894.33 attached to bed, (for example, balkan, 4 poster) E0947 Fracture frame, attachments for complex B.R. pelvic traction E0948 Fracture frame, attachments for complex B.R. cervical traction E0950 Tray 82.96 E0951 Loop heel, each 15.04 E0952 Loop toe, each 15.04 E0953 Pneumatic tire, each 92.59


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E0954 Semi-pneumatic caster, each 47.46 E0958 Wheelchair attachment to convert 421.32 any wheelchair to one arm drive E0959 Amputee adapter (device used to compensate 73.82 for transfer of weight due to lost limbs to maintain proper balance) E0961 Brake extension, for wheelchair 11.61 E0962 1' cushion, for wheelchair 47.46 E0963 2' cushion, for wheelchair 61.17 E0964 3' cushion, for wheelchair 70.66 E0965 4' cushion, for wheelchair 79.10 E0966 Hook-on headrest extension 51.67 E0967 Wheelchair hand rims with 8 vertical 105.46 rubber-tipped projections, pair E0968 Commode seat, wheelchair 181.39 E0969 Narrowing device, wheelchair B.R. E0970 No. 2 footplates, except for elevating 94.92 leg rest E0971 Anti-tipping device wheelchairs 50.28 E0972 Transfer board, wheelchair B.R. E0973 Adjustable height detachable arms, 91.75 desk or full length, wheelchair E0974 "Grade-aid" (device to prevent rolling 68.56 back on an incline) for wheelchair E0975 Reinforced seat upholstery, wheelchair 55.89 E0976 Reinforced back, wheelchair, upholstery 55.89 or other material E0977 Wedge cushion, wheelchair 49.57 E0978 Belt, safety with airplane buckle, 36.92 wheelchair E0979 Belt, safety with velcro closure, 25.93 wheelchair E0980 Safety vest, wheelchair 26.37 E0990 Elevating leg rest, each 77.14 E0991 Upholstery seat 36.92 E0992 Solid seat insert 43.49 E0993 Back, upholstery 27.97 E0994 Armrest, each 13.42 E0995 Calf rest, each 21.09 E0996 Tire, solid, each 23.07 E0997 Caster with a fork 56.95 E0998 Caster without fork 31.64


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E0999 Pneumatic tire with wheel 91.75 E1000 Tire, pneumatic caster 49.57 E1001 Wheel, single 92.81 E1031 Rollabout chair, any and all types with B.R. castors 5' or greater E1050 Fully-reclining wheelchair, fixed 1,222.53 full-length arms, swing away detachable elevating leg rests E1060 Fully-reclining wheelchair, detachable 1,222.53 arms, desk or full-length, swing away detachable elevating leg rests E1065 Power attachment (to convert any wheelchair 2,404.55 to motorized wheelchair (for example, solo) E1066 Battery charger 242.56 E1069 Deep cycle battery 92.99 E1070 Fully-reclining wheelchair, detachable 909.61 arms, desk or full-length, swing away detachable foot rest E1083 Hemi-wheelchair, fixed full-length arms, 717.15 swing away detachable elevating leg rests E1084 Hemi-wheelchairs, detachable arms, desk 1,049.29 or full-length arms, swing away detachable elevating leg rests E1085 Hemi-wheelchair, fixed full-length arms, 829.21 swing away detachable foot rests E1086 Hemi-wheelchair, detachable arms, desk 1,105.41 or full-length, swing away detachable foot rests E1087 High strength lightweight wheelchair, 1,152.71 fixed-full length arms, swing away detachable leg rests E1088 High strength lightweight wheelchair, 1,536.80 detachable arms, desk or full-length, swing away detachable elevating leg rests E1089 High strength lightweight wheelchair, 1,133.99 fixed length arms, swing away detachable foot rest E1090 High strength lightweight wheelchair, 1,499.05 detachable arms, desk or full-length, swing away detachable foot rests E1091 Youth wheelchair, any type 1,335.05 E1092 Wide heavy duty wheelchair, detachable 1,367.22


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arms, desk or full-length, swing away detachable elevating leg rests E1093 Wide heavy duty wheelchair, detachable 1,255.01 arms, desk or full-length arms, swing away detachable foot rests E1100 Semi-reclining wheelchair, fixed 1,054.63 full-length arms, swing away detachable elevating leg rests E1110 Semi-reclining wheelchair, detachable 1,139.73 arms, desk or full-length, elevating leg rests E1130 Standard wheelchair, fixed full-length 424.49 arms, fixed or swing away detachable foot rests E1140 Wheelchair, detachable arms, 697.26 desk or full-length, swing away detachable foot rests E1150 Wheelchair, detachable arms, desk or 776.52 full-length, swing away detachable elevating leg rests E1160 Wheelchair, fixed full-length arms, 601.55 swing away detachable elevating leg rests E1170 Amputee wheelchair, fixed full 1,179.70 length arms, swing away detachable elevating leg rests E1171 Amputee wheelchair, fixed full length 682.35 arms, without foot rests or leg rests E1172 Amputee wheelchair, detachable arms 877.45 (desk or full-length) without foot rests or leg rests E1180 Amputee wheelchair, detachable arms 937.91 (desk or full-length) swing away detachable foot rests E1190 Amputee wheelchair, detachable arms 1,083.63 (desk or full-length) swing away detachable elevating leg rests E1195 Heavy duty wheelchair, fixed 1,029.11 full-length arms, swing away detachable elevating leg rests E1200 Amputee wheelchair, fixed full-length 807.14 arms, swing away detachable foot rest E1210 Motorized wheelchair, fixed full-length 3,646.69 arms, swing away detachable elevating


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leg rests E1211 Motorized wheelchair, detachable arms 3,269.35 (desk or full-length) swing away, detachable elevating leg rests E1212 Motorized wheelchair, fixed 2,913.94 full-length arms, swing away detachable foot rests E1213 Motorized wheelchair, detachable arms 3,269.35 (desk or full-length) swing away detachable foot rests E1220 Wheelchair; specially sized or constructed B.R. (indicate brand name, model number, and justification) E1221 Wheelchair with fixed arm, foot rests 758.38 E1222 Wheelchair with fixed arm, elevating leg rest 955.49 E1223 Wheelchair with detachable arms, 831.05 foot rests E1224 Wheelchair with detachable arms, 1,174.02 elevating leg rests E1225 Semi-reclining back for customized 449.27 wheelchair E1226 Full-reclining back for customized 514.66 wheelchair E1227 Special height arms for wheelchair 221.47 E1228 Special back height for wheelchair 189.83 E1230 Power operated vehicle (three or four 1,624.13 wheel nonhighway), specify brand name and model number E1240 Lightweight wheelchair, detachable 1,057.14 arms, (desk or full-length) swing away detachable, elevating leg rest E1250 Lightweight wheelchair, fixed 630.67 full-length arms, swing away detachable foot rest E1260 Lightweight wheelchair, detachable 870.81 arms, (desk or full-length)swing away detachable foot rest E1270 Lightweight wheelchair, fixed 727.69 full-length arms, swing away detachable elevating leg rests E1280 Heavy duty wheelchair, detachable 1,272.04 arms (desk or full-length) elevating


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leg rests E1285 Heavy duty wheelchair, fixed 999.66 full-length arms, swing away detachable foot rest E1290 Heavy duty wheelchair, detachable 1,386.25 arms (desk or full-length) swing away detachable foot rest E1295 Heavy duty wheelchair, fixed 943.05 full-length arms, elevating leg rest E1296 Special wheelchair seat height from 282.64 the floor E1297 Special wheelchair seat depth, by 61.17 upholstery E1298 Special wheelchair seat depth and/or 304.78 width, by construction E1300 Whirlpool, portable (overtub type) B.R. E1310 Whirlpool, nonportable (built-in type) 3,269.35 E1350 Repair or nonroutine service (for example, 40.00 breaking down sealed components) requiring (per hour) the skill of a technician E1353 Regulator B.R. E1355 Stand/rack 46.67 E1372 Immersion external heater for nebulizer 179.29 E1375 Nebulizer, portable with small compressor, 174.02 with limited flow E1377 Oxygen concentrator, high humidity 250.00 system equiv. to 244 cu. ft. (per month) E1378 Oxygen concentrator, high humidity 250.00 system equiv. to 488 cu. ft. (per month) E1379 Oxygen concentrator, high humidity system 250.00 equiv. to 732 cu. ft. (per month) E1380 Oxygen concentrator, high humidity system 250.00 equiv. to 976 cu.ft. (per month) E1381 Oxygen concentrator, high humidity system 250.00 equiv. to 1220 cu. ft. (per month) E1382 Oxygen concentrator, high humidity system 250.00


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equiv. to 1464 cu. ft. (per month) E1383 Oxygen concentrator, high humidity system 250.00 equiv. to 1708 cu. ft. (per month) E1384 Oxygen concentrator, high humidity system 250.00 equiv. to 1952 cu. ft. (per month) E1385 Oxygen concentrator, high humidity system 250.00 equiv. to over 1952 cu. ft. (per month) E1399 Durable medical equipment, miscellaneous B.R. E1400 Oxygen concentrator, manufacturer specified maximum flow rate 250.00 does not exceed 2 liters per minute, at 85 percent or (per greater concentration month) E1401 Oxygen concentrator, manufacturer specified maximum flow rate 250.00 greater than 2 liters per minute, does not exceed 3 liters (per per minute, at 85 percent or greater concentration month) E1402 Oxygen concentrator, manufacturer specified maximum flow rate 250.00 greater than 3 liters per minute, does not exceed 4 liters (per per minute, at 85 percent or greater concentration month) E1403 Oxygen concentrator, manufacturer specified maximum flow rate 250.00 greater than 4 liters per minute, does not exceed 5 liters (per per minute, at 85 percent or greater concentration month) E1404 Oxygen concentrator, manufacturer specified B.R. maximum flow rate greater than 5 liters per minute, at 85 percent or greater concentration E1405 Oxygen and water vapor enriching system B.R. with heated delivery E1406 Oxygen and water vapor enriching system B.R. without heated delivery E1592 Automatic intermittent peritoneal B.R. dialysis system E1594 Cycler dialysis machine for peritoneal B.R. dialysis E1610 Reverse osmosis water purification B.R. system E1615 Deionizer water purification system B.R. E1630 Reciprocating peritoneal dialysis system B.R. E1632 Wearable artificial kidney B.R. E1640 Replacement components for hemodialysis B.R. and/or peritoneal dialysis machines that


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are owned or being purchased by the patient E1699 Dialysis equipment, unspecified, by report B.R. E1700 Jaw motion rehabilitation system B.R. E1701 Replacement cushions for jaw motion B.R. rehabilitation system, pkg. of 6 E1702 Replacement measuring scales for jaw B.R. motion rehabilitation system, pkg. of 200 E1800 Dynamic adjustable elbow extension/flexion device B.R. E1805 Dynamic adjustable wrist extension/flexion device B.R. E1810 Dynamic adjustable knee extension/flexion device B.R. E1815 Dynamic adjustable ankle extension/flexion device B.R. E1820 Soft interface material, dynamic adjustable extension/flexion B.R. device E1825 Dynamic adjustable finger extension/flexion device B.R. E1830 Dynamic adjustable toe extension/flexion device B.R. K0001 Standard wheelchair 539.00 K0002 Standard hemi (low seat) wheelchair 870.00 K0003 Lightweight wheelchair 802.00 K0004 High strength, lightweight wheelchair 1,385.00 K0005 Ultra lightweight wheelchair B.R. K0006 Heavy duty wheelchair 1,274.00 K0007 Extra heavy duty wheelchair B.R. K0008 Custom manual wheelchair/base B.R. K0009 Other manual wheelchair/base B.R. K0010 Standard-weight frame motorized/power 3,345.00 wheelchair K0011 Standard-weight frame motorized/power B.R. wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking K0012 Lightweight portable motorized/power B.R. wheelchair K0013 Custom motorized/power wheelchair base B.R. K0014 Other motorized/power wheelchair base B.R. K0015 Detachable, nonadjustable height 157.00 armrest, each K0016 Detachable, adjustable height armrest, 100.00 complete assembly, each K0017 Detachable, adjustable height armrest, B.R. base, each K0018 Detachable, adjustable height armrest, B.R.


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upper portion, each K0019 Arm pad, each B.R. K0020 Fixed, adjustable height armrest, pair B.R. K0021 Anti-tipping device, each 54.00 K0022 Reinforced back upholstery 43.00 K0023 Solid back insert, planar back, single B.R. density foam, attached with straps K0024 Solid back insert, planar back, single B.R. density foam, with adjustable hook-on hardware K0025 Hook-on headrest extension 56.00 K0026 Back upholstery for ultra lightweight or 27.97 high-strength lightweight wheelchair K0027 Back upholstery for wheelchair type other 34.00 than ultra lightweight or high-strength lightweight wheelchair K0028 Fully reclining back 472.00 K0029 Reinforced seat upholstery 43.00 K0030 Solid seat insert, planar seat, single 70.00 density foam K0031 Safety belt/pelvic strap 37.00 K0032 Seat upholstery for ultra lightweight or 36.92 high-strength lightweight wheelchair K0033 Seat upholstery for wheelchair type other 36.92 than ultra lightweight or high-strength lightweight wheelchair K0034 Heel loop, each 17.00 K0035 Heel loop with ankle strap, each B.R. K0036 Toe loop, each 17.00 K0037 High mount flip-up footrest, each 47.46 K0038 Leg strap, each B.R. K0039 Leg strap, H style, each B.R. K0040 Adjustable angle footplate, each B.R. K0041 Large size footplate, each B.R. K0042 Standard size footplate, each 32.00 K0043 Footrest, lower extension tube, each B.R. K0044 Footrest, upper hanger bracket, each B.R. K0045 Footrest, complete assembly B.R. K0046 Elevating legrest, lower extension B.R. tube, each K0047 Elevating legrest, upper hanger bracket, B.R. each


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K0048 Elevating legrest, complete assembly 87.00 K0049 Calf pad, each 23.00 K0050 Ratchet assembly B.R. K0051 Cam release assembly, footrest or legrest, each B.R. K0052 Swingaway, detachable footrests, each B.R. K0053 Elevating footrests, articulating B.R. (telescoping), each K0054 Seat width of 10', 11', 12', 15', 17', B.R. or 20'for a high strength, lightweight or ultra lightweight wheelchair K0055 Seat depth of 15', 17', or 18' for a B.R. high strength lightweight or ultra lightweight wheelchair K0056 Seat height less than 17' or less than 83.00 or equal to 21' for a high strength, lightweight or ultra lightweight wheelchair K0057 Seat width 19' or 20' for heavy duty 107.00 or extra heavy duty chair K0058 Seat depth 17' or 18' for motorized/ 52.00 power wheelchair K0059 Plastic coated handrim, each B.R. K0060 Steel handrim, each B.R. K0061 Aluminum handrim, each B.R. K0062 Handrim with 8-10 vertical or 53.00 oblique projections, each K0063 Handrim with 12-16 vertical or B.R. oblique projections, each K0064 Zero pressure tube (flat free inserts), B.R. any size, each K0065 Spoke protectors B.R. K0066 Solid tire, any size, each 25.00 K0067 Pneumatic tire, any size, each 35.00 K0068 Pneumatic tire tube, each B.R. K0069 Rear wheel assembly, complete with solid 87.00 tire, spokes or molded, each K0070 Rear wheel assembly, complete, with 158.00 pneumatic tire, spokes or molded, each K0071 Front caster assembly, complete, with B.R. pneumatic tire, each K0072 Front caster assembly, complete, with 57.00 semi-pneumatic tire, each


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K0073 Caster pinlock, each B.R. K0074 Pneumatic caster tire, any size, each 31.00 K0075 Semi-pneumatic caster tire, any size, 47.46 each K0076 Solid caster tire, any size, each B.R. K0077 Front caster assembly, complete, with B.R. solid tire, each K0078 Pneumatic caster tire tube, each B.R. K0079 Wheel lock extension, pair 43.00 K0080 Anti-rollback device, pair 136.00 K0081 Wheel lock assembly, complete, each B.R. K0082 22 NF deep cycle lead acid battery, 92.99 each K0083 22 NF gel cell battery, each B.R. K0084 Group 24 deep cycle lead acid battery, B.R. each K0085 Group 24 gel cell battery, each B.R. K0086 U-1 lead acid battery, each 92.99 K0087 U-1 gel cell battery, each B.R. K0088 Battery charger, lead acid or gel cell 242.56 K0089 Battery charger, dual mode B.R. K0090 Rear wheel tire for power wheelchair, B.R. any size, each K0091 Rear wheel tire tube other than zero B.R. pressure for power wheelchair, any size, each K0092 Rear wheel assembly for power wheelchair, B.R. complete, each K0093 Rear wheel zero pressure tire tube (flat B.R. free insert) for power wheelchair, any size, each K0094 Wheel tire for power base, any size, each B.R. K0095 Wheel tire tube other than zero pressure B.R. for each base, any size, each K0096 Wheel assembly for power base, complete, B.R. each K0097 Wheel zero pressure tire tube (flat free B.R. insert) for power base, any size, each K0098 Drive belt for power wheelchair B.R. K0099 Front caster for power wheelchair B.R. K0100 Amputee adapter, pair 77.00 K0101 One-arm drive attachment 449.00


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K0102 Crutch and cane holder B.R. K0103 Transfer board, less than 25 inches B.R. K0104 Cylinder tank carrier B.R. K0105 IV hanger B.R. K0106 Arm trough, each B.R. K0107 Wheelchair tray 89.00 K0108 Other accessories B.R. K0109 Customization of wheelchair base frame B.R. (options or accessories) K0112 Trunk support device, vest type, with B.R. inner frame, prefabricated K0113 Trunk support device, vest type, without B.R. inner frame, prefabricated K0114 Back support system for use with a B.R. wheelchair, with inner frame, prefabricated K0115 Orthotic seating system, back module, B.R. posterior--lateral control, with or without lateral supports, custom fabricated, for attachment to wheelchair base K0116 Orthotic seating system, combined back B.R. and seat module, custom fabricated, for attachment to wheelchair base K0126 Replace soft interface material, B.R. multi-podus type splint K0127 Replace soft interface material, ankle B.R. contracture splint K0128 Replace soft interface material, foot B.R. drop splint K0129 Ankle contracture splint B.R. K0130 Foot drop splint, recumbent positioning B.R. device K0137 Skin barrier; liquid (spray brush, etc.) B.R. per oz. K0138 Skin barrier; paste, per oz. B.R. K0139 Skin barrier, powder, per oz. B.R. K0152 Pastes, powders, granules, beads, B.R. contact layers K0163 Vacuum erection system B.R. tracheostomy K0168 Administration set, small volume B.R. pneumatic nebulizer, disposable


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K0169 Small volume nonfiltered pneumatic B.R. nebulizer, disposable K0170 Administration set, small volume non- B.R. filtered pneumatic nebulizer, non- disposable K0171 Administration set, small volume B.R. nonfiltered pneumatic nebulizer K0172 Large volume nebulizer, disposable, B.R. unfilled, used with aerosol compressor K0173 Large volume nebulizer, disposable, B.R. prefilled, used with aerosol compressor K0174 Reservoir bottle, non-disposable, used B.R. with large volume ultrasonic nebulizer K0175 Corrugated tubing, disposable, used with B.R. large volume nebulizer, 100 feet K0176 Corrugated tubing, non-disposable, used B.R. with large volume nebulizer, 100 feet K0177 Water collection device, used with large B.R. volume nebulizer K0178 Filter, disposable, used with aerosol B.R. compressor K0179 Filter, non-disposable, used with aerosol B.R. compressor or ultrasonic generator K0180 Aerosol mask, used with DME nebulizer B.R. K0181 Dome and mouthpiece, used with small B.R. volume ultrasonic nebulizer K0182 Water, distilled, used with large volume B.R. nebulizer, 1000 ml K0183 Nasal application device, used with B.R. CPAP device K0184 Nasal pillows/seals, replacement for B.R. nasal application device, pair K0185 Headgear, used with CPAP device B.R. K0186 Chin strap, used with CPAP device B.R. K0187 Tubing, used with CPAP device B.R. K0188 Filter, disposable, used with CPAP B.R. device K0189 Filter, non-disposable, used with B.R. CPAP device K0190 Canister, disposable, used with B.R. suction pump K0191 Canister, non-disposable, used with B.R.


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suction pump K0192 Tubing, used with suction pump B.R. K0193 Continuous positive airway pressure B.R. (CPAP) device, with humidifier K0194 Intermittent assist device with B.R. continuous positive airway pressure (CPAP), with humidifier K0195 Elevating leg rest, pair (for use B.R. with capped rental wheelchair base) K0249 Hydrogel dressing, wound filler, dry form,per gram B.R K0268 Humidifier, used with CPAP device B.R. K0277 Skin barrier; solid 4x4 or equivalent, with built-in B.R. convexity, each K0278 Skin barrier; with flange (solid, flexible or accordion), B.R. with built-in convexity, any size, each K0280 Extension drainage tubing, any type, any length, with B.R connector/adaptor, for use with urinary leg bag or urostomy pouch, each K0281 Lubricant, individual sterile packet, for insertion of B.R. urinary catheter, each K0283 Saline solution, per 10 ML, metered dose dispenser, B.R

for use with inhalation drugs K0284 External infusion pump, mechanical, reusable, for B.R.

extended drug infusion K0400 Adhesive skin support attachment for use with external B.R.

Breast prosthesis, each K0401 For diabetics only, deluxe feature of off-the-shelf depth B.R. inlay shoe or custom molded shoe, per shoe K0407 Urinary catheter anchoring device, adhesive skin B.R.

attachment K0408 Urinary catheter anchoring device, leg strap B.R. K0409 Sterile water irrigation solution, 1000 ML B.R. K0410 Male external catheter, with adhesive coating, each B.R. K0411 Male external catheter, with adhesive strip, each B.R. K0413 Non-powdered adjustable zone pressure reducing overlay B.R. K0414 Powered overlay for mattress B.R. K0417 External infusion pump, mechanical reusable, for short term B.R. during infusion plastic K0456 Hospital bed, heavy duty, extra wide, with any type side B.R. rails, with mattress K0457 Extra wide/heavy duty commode chair, each B.R.


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K0458 Heavy duty walker, without wheels, each B.R. K0459 Heavy duty wheeled walker, each B.R. K0460 Power add-on, to convert manual wheelchair to B.R.

motorized wheel chair, joystick control K0461 Power add-on, to convert manual wheelchair to B.R. motorized wheel chair, tiller control L0210 Thoracic rib belt, custom fitted 13.20 L0300 Thoracic-lumbar-sacral-orthoses (TLSO), 101.68 flexible (dorso-lumbar surgical support), custom fitted L0315 TLSO, flexible dorso-lumbar surgical 120.00 support L0500 Lumbar-sacral-orthoses (LSO), flexible, 77.28 (lumbo-sacral surgical supports), custom fitted L0515 LSO, flexible (lumbo-sacral surgical 69.16 support), elastic type, with rigid posterior panel L0600 Sacroiliac, flexible (sacroiliac surgical 40.72 support), custom fitted L0900 Torso support, ptosis support, custom 102.11 fitted L0920 Torso support, pendulous abdomen 118.36 support, custom fitted L0940 Torso support, postsurgical support, 110.18 custom fitted L0960 Torso support, postsurgical support 48.71 pads, for postsurgical support L0974 TLSO, full corset 88.20 L0976 LSO, full corset 103.88 L0980 Peroneal straps, pair 11.33 L0982 Stocking supporter grips, set of 9.60 four (4) L1600 Hip orthoses (HO), abduction control 40.32 of hip joints, flexible, Frejka type with cover L1610 HO, abduction control of hip joints, flexible, 25.00 flexible, (Frejka cover only) L1620 HO, abduction control of hip joints, flexible, 75.00 (Pavlik harness) L1800 Knee orthosis (KO), elastic with stays 32.56 L1810 KO, elastic with joints 61.04


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L1815 KO, elastic with condylar pads 63.19 L1820 KO, elastic with condyle pads and joints 72.40 L1825 KO, elastic knee cap 28.00 L1830 KO, immobilizer; canvas longitudinal 52.88 L1902 AFO, ankle gauntlet, custom fitted 48.81 L1906 AFO, multiligamentus ankle support 75.00 L3201 Orthopedic shoe, oxford with supinator 48.00 or pronator, infant L3202 Orthopedic shoe, oxford with supinator 48.00 or pronator, child L3203 Orthopedic shoe, oxford with supinator 48.00 or pronator, junior L3204 Orthopedic shoe, hightop with supinator 48.00 or pronator, infant L3206 Orthopedic shoe, hightop with supinator 48.00 or pronator, child L3207 Orthopedic shoe, hightop with supinator 48.00 or pronator, junior L3208 Surgical boot, each, infant 24.00 L3209 Surgical boot, each, child 24.00 L3211 Surgical boot, each, junior 24.00 L3212 Benesch boot, pair, infant 48.00 L3213 Benesch boot, pair, child 48.00 L3214 Benesch boot, pair, junior 48.00 L3215 Orthopedic footwear, woman's shoes, 76.00 oxford L3216 Orthopedic footwear, woman's shoes, 100.00 depth inlay L3217 Orthopedic footwear, woman's shoes, 116.00 hightop, depth inlay L3218 Orthopedic footwear, woman's surgical 64.00 boot, each L3219 Orthopedic footwear, man's shoes, 76.00 oxford L3221 Orthopedic footwear, man's shoes, 100.00 depth inlay L3222 Orthopedic footwear, man's shoes, 116.00 hightop, depth inlay L3223 Orthopedic footwear, man's surgical 64.00 boot, each L3253 Foot, molded shoe Plastazote 112.00 (or similar), custom fitted, each


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L3254 Nonstandard size or width 20.00 L3255 Nonstandard size or length 20.00 L3257 Orthopedic footwear, additional 50.00 charge for split size L3260 Ambulatory surgical boot, each 88.00 L3265 Plastazote sandal, each 56.00 L3300 Lift, elevation, heel, tapered to 64.00 metatarsals, per inch L3310 Lift, elevation, heel and sole, 64.00 neoprene, per inch L3320 Lift, elevation, heel and sole, 100.00 cork, per inch L3332 Lift, elevation, inside shoe, tapered, 44.00 up to one-half inch L3334 Lift, elevation, heel, per inch 36.00 L3340 Heel wedge, sach 10.40 L3350 Heel wedge 12.00 L3360 Sole wedge, outside sole 12.00 L3370 Sole wedge, between sole 14.40 L3380 Clubfoot wedge 12.00 L3390 Outflare wedge 16.00 L3400 Metatarsal bar wedge, rocker 16.00 L3410 Metatarsal bar wedge, between sole 16.00 L3420 Full sole and heel wedge, between sole 24.00 L3430 Heel, counter, plastic reinforced 24.00 L3440 Heel, counter, leather reinforced 24.00 L3450 Heel, Sach cushion type 64.00 L3455 Heel, new leather, standard 8.00 L3460 Heel, new rubber, standard 8.00 L3465 Heel, Thomas with wedge 20.00 L3470 Heel, Thomas extended to ball 24.00 L3480 Heel, pad and depression for spur 16.00 L3485 Heel, pad, removable for spur 32.00 L3500 Miscellaneous shoe addition, insole, 4.00 leather L3510 Miscellaneous shoe addition, insole, 8.00 rubber L3520 Miscellaneous shoe additions, insole, 8.00 felt covered with leather L3530 Miscellaneous shoe addition, sole, 12.00 half L3540 Miscellaneous shoe addition, sole, 36.00


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full L3550 Miscellaneous shoe addition, toe tap, 4.00 standard L3560 Miscellaneous shoe addition, toe 6.40 tap, horseshoe L3570 Miscellaneous shoe addition, 152.00 special extension to instep (leather with eyelets) L3580 Miscellaneous shoe addition, 13.60 convert instep to velcro closure L3590 Miscellaneous shoe addition, 28.00 convert firm shoe counter to soft counter L3595 Miscellaneous shoe addition, 12.00 March bar L3600 Transfer of an orthosis from one 48.00 shoe to another, caliper plate, existing L3610 Transfer of an orthosis from one 76.00 shoe to another, caliper plate, new L3620 Transfer of an orthosis from one 39.04 shoe to another, solid stirrup, existing L3630 Transfer of an orthosis from one 6.00 shoe to another, solid stirrup, new L3640 Transfer of an orthosis from one 28.00 shoe to another, Dennis Browne splint (Riveton), both shoes L3649 Unlisted procedures for foot orthopedic B.R. shoes, shoe modifications and transfers L3800 Wrist-hand-finger-orthoses (WHFO), 124.28 short opponens, no attachments L3908 WHFO, wrist extension control cock-up, 50.13 nonmolded L3914 WHFO, wrist extension cock-up 60.00 L3916 WHFO, wrist extension cock-up, 72.00 with outrigger L8000 Breast prosthesis, mastectomy bra B.R. L8010 Breast prosthesis, mastectomy sleeve 40.56 L8020 Breast prosthesis, mastectomy form 132.00


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L8030 Breast prosthesis, silicone or equal B.R. L8100 Elastic support, elastic stocking, 24.00 below knee, medium weight, each L8110 Elastic support, elastic stocking, 30.40 below knee, heavy weight, each L8120 Elastic support, elastic stocking, 32.00 below knee, surgical weight, (Linton type or equal), each L8130 Elastic support, elastic stocking, 33.60 above knee, medium weight, each L8140 Elastic support, elastic stocking, 36.00 above knee, heavy weight, each L8150 Elastic support, elastic stocking, 44.00 above knee, surgical weight, (Linton type or equal), each L8160 Elastic support, elastic stocking, 40.00 full-length, medium weight, each L8170 Elastic support, elastic stocking, 48.00 full-length, heavy weight, each L8180 Elastic support, elastic stocking, 52.00 full-length, heavy surgical weight (Linton type or equal), each L8190 Elastic support, elastic stocking, 108.00 leotards, medium weight, each L8200 Elastic supports, elastic stocking, 120.00 leotards surgical weight (Linton type), each L8210 Elastic support, elastic stocking, B.R. custom-made L8220 Elastic support, elastic stocking, B.R. lymphedema L8230 Elastic support, elastic stocking, B.R. garter belt L8300 Truss, single with standard pad 51.28 L8310 Truss, double with standard pads 101.68 L8320 Truss, addition to standard pad, 24.00 water pad L8330 Truss, addition to standard pad, 33.65 scrotal pad L8400 Prosthetic sheath, below knee, each 12.00 L8410 Prosthetic sheath, above knee, each 12.00 L8415 Prosthetic sheath, upper limb, each 11.20


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L8420 Prosthetic sock, wool, below knee, each 14.94 L8430 Prosthetic sock, wool, above knee, each 18.40 L8435 Prosthetic sock, wool, upper limb, each 8.14 L8440 Prosthetic shrinker, below knee, each 33.60 L8460 Prosthetic shrinker, above knee, each 41.60 L8465 Prosthetic shrinker, upper limb, each 33.60 L8470 Stump sock, single ply, fitting, below 2.52 knee, each L8480 Stump sock, single ply, fitting, above 2.52 knee, each X4810 Velcro straps, attached to a pair 14.00 of shoes, per pair X4850 Space shoe rubber raise for shoe: 8.00 1/4 ' raise X4851 Space shoe rubber raise for shoe: 9.00 1/2 ' raise X4852 Space shoe rubber raise for shoe: 13.00 3/4 ' raise X4853 Space shoe rubber raise for shoe: 20.00 1' raise X4854 Space shoe rubber raise for shoe: 8.00 Each addition 1/2 ' raise X4890 Foot casting 50.00 X4891 Foot, ankle casting 65.00 X4892 Foot, ankle, shin casting 70.00 X6005 Two piece flange, stoma size: 4' 4.70/unit and two piece flange, stoma size: 3 1/4 ', "picture frame" design X6460 Ostomy deodorant B.R. X7200 Hypodermic syringes over 5cc B.R. X7300 Rectal syringes B.R. X7520 Disposable briefs/diapers, any size $0.70/un- X7533 Adult diapers/briefs with elasticized waistbands, large or $0.90/un- extra X8200 Augmentative communication device B.R. X8334 Parenteral infusion by gravity (includes parenteral therapy $39.00/d- supplies and base solution cost) ay X8335 Parenteral infusion by disposable pump (includes $39.00/d-

supplies and base solution cost ay X8336 Parenteral infusion with external ambulatory infusion pump $60.00/d- and administration equipment (includes pump, supplies

and ay base solution cost)


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X8337 Parenteral line maintenance (includes all supplies $8.00/day Necessary)

X8338 Elastomeric infusion system 19.85 (disposable pumps) (per pump) X8339 Gloves, sterile, each . 30 X8433 Gloves, non-sterile, each .09 X8434 Parenteral infusion with external stationary pump and $39.00/d- administration equipment (includes pump, supplies and base ay solution cost)


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60

NEW JERSEY ADMINISTRATIVE CODE TITLE 10. DEPARTMENT OF HUMAN SERVICES

CHAPTER 59. MEDICAL SUPPLIER MANUAL APPENDIX A

Current through July 16, 2001;33 N.J. Reg. No. 14

SERVICE STATUS AND PA REQUIREMENTS FOR HCPCS CODES

AGENCY NOTE: Appendix A includes certain values for service status and Prior Authorization (PA) as defined below.

Rental Indicator Values N = cannot be rented; D = can only be rented daily (1 unit = 1 day); and M = can be rented monthly (1 unit = 1 month)

Purchase Indicator Values N = cannot be purchased; D = DME item which can be purchased; M = medical supply or service which cannot be rented; and P = Prosthetic or orthotic which cannot be rented

Prior Authorization Values A = prior authorization required; and N = prior authorization not required

Notations


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For example, common medical supply items will have a Rental Indicator Value of "N," and a Purchase Indicator Value of "M." By definition, these items cannot be rented. For example, common DME will have a Rental Indicator Value of "M," and a Purchase Indicator Value of "D." By definition, these items can be both rented or purchased. Claims for rental services shall include the procedure code modifier "PR." In addition, claims for purchases of medical supplies and DME include the procedure code modifier "NU." PROC CODE DME RENT DME PURCH PA IND IND IND A4206 N M N A4207 N M N A4208 N M N A4209 N M N A4210 N D N A4211 N M N A4212 N M N A4213 N M N A4214 N M N A4215 N M N A4230 N M A A4231 N M A A4232 N M A A4244 N M N A4245 N M N A4246 N M N A4247 N M N A4250 N M N A4253 N M A A4256 N M N A4258 N M N A4259 N M N A4265 N M N A4300 N M N A4305 N M A A4306 N M N A4310 N M N A4311 N M N A4312 N M N


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A4313 N M N A4314 N M N A4315 N M N A4316 N M N A4320 N M N A4322 N M N A4323 N M N A4326 N M A A4327 N M A A4328 N M A A4329 N M A A4330 N M N A4335 N M N A4338 N M A A4340 N M A A4344 N M A A4346 N M A A4347 N M A A4351 N M A A4352 N M A A4354 N M A A4355 N M A A4356 N M A A4357 N M A A4358 N M A A4359 N M A A4361 N M N A4362 N M N A4363 N M N A4364 N M N A4367 N M N A4397 N M N A4398 N M N A4399 N M N A4400 N M N A4402 N M N A4404 N M N A4421 N M N A4454 N M N A4455 N M N A4460 N M N A4465 N M N


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A4470 N D N A4480 N D N A4550 N M N A4554 N M A A4556 N M A A4557 N M A A4558 N M N A4560 N M N A4565 N M N A4570 N M N A4572 N M N A4575 N M A A4581 N D N A4595 N M N A4611 N M A A4612 N M N A4613 M D A A4615 N M N A4616 N M N A4617 N M A A4618 N M A A4619 N M A A4620 N M A A4621 N M A A4622 N M A A4623 N M A A4624 N M A A4625 N M A A4626 N M A A4627 N M A A4628 N M N A4629 N M N A4630 N M N A4631 N M A A4635 N M N A4636 N M N A4637 N M N A4640 N D A A4649 N M A A4655 N M N A4660 N D N A4663 N M N


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A4670 N D N A4700 N M N A4705 N M N A4712 N M N A4714 N M N A4730 N M N A4735 N M N A4740 N M N A4750 N M N A4755 N M N A4760 N M N A4765 N M N A4770 N M N A4771 N M N A4772 N M N A4773 N M N A4774 N M N A4780 N M N A4820 N M N A4850 N M N A4860 N M N A4900 N M A A4901 N M A A4905 N M A A4912 N D N A4913 N M A A4914 N M A A4918 N M N A4919 N D N A4920 N D N A4921 N D N A5051 N M N A5052 N M N A5053 N M N A5054 N M N A5055 N M N A5061 N M N A5062 N M N A5063 N M N A5064 N M N A5065 N M N A5071 N M N


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A5072 N M N A5073 N M N A5074 N M N A5075 N M N A5081 N M N A5082 N M N A5093 N M N A5102 N M N A5105 N M N A5112 N M N A5113 N M N A5114 N M N A5119 N M N A5121 N M N A5122 N M N A5123 N M N A5126 N M N A5131 N M A A6020 N M N A6196 N M N A6197 N M N A6198 N M N A6199 N M N A6203 N M N A6204 N M N A6205 N M N A6206 N M N A6207 N M N A6208 N M N A6210 N M N A6211 N M N A6212 N M N A6213 N M N A6214 N M N B4034 N M A B4035 N M A B4036 N M A B4081 N M A B4082 N M A B4083 N M A B4084 N M A B4085 N M A


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B4150 N M A B4151 N M A B4152 N M A B4153 N M A B4156 N M A B4164 N M A B4168 N M A B4172 N M A B4176 N M A B4178 N M A B4180 N M A B4186 N M A B4189 N M A B4193 N M A B4199 N M A B4202 N M N B4206 N M N B4210 N D N B4214 N M N B4216 N M A B4220 N M A B4224 N M A B4245 N M N B5000 N M A B5100 N M A B9000 M D A B9002 M D A B9004 M N A B9006 M N A B9998 N M A E0023 N M N E0036 N M A E0044 M D N E0054 N M N E0063 N M N E0072 N M N E0084 N M A E0105 M D N E0105 N M N E0110 M D N E0111 M D N E0113 M D N


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E0114 M D N E0116 M D N E0119 N M N E0126 N M N E0135 M D N E0141 M D N E0142 M D A E0145 M D N E0146 M D A E0147 M D N E0153 N M A E0154 M D N E0155 M D N E0156 N D N E0160 M D N E0161 M D N E0163 M D N E0164 M D N E0165 M D N E0167 N D N E0172 N M A E0175 M D N E0176 N D N E0178 N D N E0179 N D N E0180 M D A E0182 M D A E0184 M D A E0185 M D A E0187 M D A E0188 N D N E0189 N D N E0192 M D A E0193 D N A E0194 D N A E0202 M D A E0235 M D N E0236 M D N E0241 N D N E0242 M D N E0243 M D N E0245 M D N


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E0246 M D N E0249 M D N E0251 M D A E0253 N M A E0255 M D A E0256 M D A E0258 M D N E0261 M D A E0265 M D A E0266 M D A E0271 M D N E0272 M D N E0273 M D N E0275 M D N E0276 M D N E0277 M D A E0290 M D A E0291 M D A E0292 M D A E0294 M D A E0295 M D A E0296 M D A E0300 N M N E0305 M D N E0310 M D N E0311 N M N E0315 N M N E0325 M D N E0329 N M A E0340 N M A E0351 N M A E0356 N M A E0361 N M N E0367 N M N E0400 N M N E0424 M N A E0431 M N A E0434 M N A E0441 N M A E0442 N M A E0443 N M A E0450 M D A


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E0452 M N A E0453 M D A E0454 N M N E0457 M D A E0459 M D A E0460 M D A E0470 N D N E0480 M D A E0500 M D N E0550 M D A E0556 N M A E0560 M D A E0565 M D A E0565 N M N E0570 M D A E0580 M D A E0585 M D A E0600 M D A E0601 M N A E0605 M D A E0606 M D N E0607 N D A E0609 N D A E0610 M D A E0611 N M A E0615 M D A E0616 N M N E0620 N M A E0624 N M A E0625 M D N E0630 M D A E0630 N M N E0635 M D A E0637 N M N E0651 M D A E0652 M D A E0655 M D A E0660 N D N E0665 M D A E0666 M D A E0667 M D A E0671 M D A


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E0672 M D A E0673 M D A E0690 M D A E0700 N D N E0705 N M N E0710 N D N E0730 M D A E0731 N D N E0735 N M N E0740 M D A E0744 M D A E0746 M D A E0747 M D A E0748 N M A E0755 N D A E0760 N M N E0772 N M N E0781 M N A E0784 N D A E0791 M N A E0801 N M N E0820 N M N E0840 M D A E0860 M D A E0870 M D A E0880 M D A E0900 M D A E0901 N M A E0910 M D A E0914 N M A E0920 M D A E0921 N D N E0935 D N A E0940 M D A E0941 M D A E0943 M D N E0945 M D N E0946 M D A E0947 M D A E0948 M D A E0950 M D N E0951 M D N


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E0952 M D N E0953 M D N E0954 M D N E0958 M D A E0959 M D N E0961 M D N E0962 M D N E0963 M D N E0964 M D N E0965 M D N E0966 M D N E0967 M D N E0968 M D N E0969 M D N E0970 M D N E0971 M D N E0972 M D N E0973 M D N E0974 M D N E0975 M D N E0976 M D N E0977 M D N E0978 M D N E0979 M D N E0980 M D N E0990 M D N E0991 M D N E0992 M D N E0993 M D N E0994 M D N E0995 M D N E0996 M D N E0997 M D N E0998 M D N E0999 M D N E1000 M D N E1001 M D N E1031 M D A E1050 M D A E1060 M D A E1065 M D A E1066 M D N


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E1069 M D N E1070 M D A E1083 M D A E1084 M D A E1085 M D A E1086 M D A E1087 M D A E1088 M D A E1089 M D A E1090 M D A E1091 M D A E1092 M D A E1093 M D A E1100 M D A E1110 M D A E1130 M D A E1140 M D A E1150 M D A E1160 M D A E1170 M D A E1171 M D A E1172 M D A E1180 M D A E1190 M D A E1195 M D A E1200 M D A E1210 M D A E1211 M D A E1212 M D A E1213 M D A E1220 M D A E1221 M D A E1111 M D A E1223 M D A E1225 M D N E1226 M D A E1227 M D N E1228 M D N E1230 M D A E1240 M D A E1250 M D A E1260 M D A


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E1270 M D A E1280 M D A E1285 M D A E1290 M D A E1295 M D A E1296 M D N E1297 M D N E1298 M D A E1300 M D A E1310 M D A E1350 M D A E1353 M D A E1355 M D A E1372 M D A E1375 M D A E1377 M N A E1378 M N A E1379 M N A E1380 M N A E1381 M N A E1382 M N A E1383 M N A E3846 M N A E1385 M N A E1399 M D A E1400 M D A E1401 M D A E1402 M D A E1403 M D A E1404 M D A E1405 M D A E1406 M D A E1592 M D A E1594 M D A E1610 M D A E1615 M D A E1630 M D A E1632 M D A E1640 M D A E1699 M D A E1700 M D A E1701 N D A


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E1702 M D N E1800 M D A E1805 M D A E1810 M D A E1815 M D A E1820 M D A E1825 M D A E1830 M D A E1924 M D A K0001 M D A K0002 M D N K0003 M D A K0004 M D A K0005 M D A K0006 M D A K0007 M D A K0008 M D A K0009 M D A K0010 M D A K0011 M D A K0012 M D A K0013 M D A K0014 M D A K0015 M D N K0016 M D N K0017 M D N K0018 M D N K0019 M D N K0020 M D N K0021 M D N K0022 M D N K0023 M D N K0024 M D N K0025 M D N K0026 M D N K0027 M D N K0028 M D A K0029 M D N K0030 M D N K0031 N D N K0032 M D N K0033 M D N


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K0034 M D N K0035 M D N K0036 M D N K0037 M D N K0038 M D N K0039 M D N K0040 M D N K0041 M D N K0042 M D N K0043 M D N K0044 M D N K0045 M D N K0046 M D N K0047 M D N K0048 M D N K0049 M D N K0050 M D N K0051 N D N K0052 M D N K0053 N D N K0054 M D N K0055 M D N K0056 M D N K0057 M D N K0058 M D N K0059 M D N K0060 M D N K0061 M D N K0062 M D N K0063 M D N K0064 M D N K0065 M D N K0066 M D N K0067 M D N K0068 M D N K0069 M D N K0070 M D N K0071 M D N K0072 M D N K0073 M D N K0074 M D N K0075 M D N


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K0076 M D N K0077 M D N K0078 M D N K0079 M D N K0080 M D N K0081 M D N K0082 M D N K0083 N D N K0084 M D N K0085 M D N K0086 M D N K0087 M D N K0088 M D N K0089 M D N K0090 M D N K0091 M D N K0092 M D N K0093 M D N K0094 M D N K0095 M D N K0096 M D N K0097 M D N K0098 M D N K0099 M D N K0100 M D N K0101 M D A K0102 M D N K0103 M D N K0104 M D N K0105 M D N K0106 M D N K0107 M D N K0108 M D A K0109 M D A K0112 N P N K0113 N P N K0114 N P N K0115 N P N K0116 N P N K0126 N P N K0127 N P N K0128 N P N


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K0129 N P N K0130 N P N K0137 N M N K0138 N M N K0139 N M N K0152 N P N K0163 M D A K0168 N M A K0169 N M A K0170 N M A K0171 N M A K0172 N M A K0173 N M A K0174 N M N K0175 N M A K0176 N M A K0177 N M A K0178 N M A K0179 N M A K0180 N M A K0181 N M A K0182 N M A K0183 N M N K0184 N M N K0185 N M N K0186 N M N K0187 N M N K0188 N M N K0189 N M N K0190 N M N K0191 N M N K0192 N M N K0193 M D A K0194 M D A K0195 N D N L0110 N P N L0120 N P N L0140 N P N L0172 N P N L0210 N P N L0300 N P N L0315 N P N


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L0500 N P N L0515 N P N L0600 N P N L0900 N P N L0920 N P N L0940 N P N L0960 N P N L0974 N P N L0976 N P N L0980 N P N L0982 N P N L1600 N P N L1610 N P N L1620 N P N L1800 N P N L1810 N P N L1815 N P N L1820 N P N L1825 N P N L1830 N P N L1902 N P N L1906 N P N L2210 N P N L2270 N P N L2360 N P N L2999 N P N L3000 N P A L3001 N P A L3002 N P A L3003 N P A L3010 N P A L3020 N P A L3030 N P A L3040 N P A L3050 N P A L3060 N P A L3070 N P A L3080 N P A L3090 N P A L3100 N P A L3140 N P A L3150 N P A


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L3170 N P A L3201 N P A L3202 N P A L3203 N P A L3204 N P A L3206 N P A L3207 N P A L3208 N P A L3209 N P A L3211 N P A L3212 N P A L3213 N P A L3214 N P A L3215 N P A L3216 N P A L3217 N P A L3218 N P A L3219 N P A L3221 N P A L3222 N P A L3223 N P A L3230 N P A L3250 N P A L3250 N P A L3252 N P A L3253 N P A L3254 N P A L3255 N P A L3257 N P A L3260 N P A L3265 N P A L3300 N P A L3310 N P A L3320 N P A L3330 N P A L3332 N P A L3334 N P A L3340 N P N L3350 N P N L3360 N P N L3370 N P N L3380 N P N


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L3390 N P N L3400 N P N L3410 N P N L3420 N P N L3430 N P N L3440 N P N L3450 N P N L3455 N P N L3460 N P N L3465 N P N L3470 N P N L3480 N P N L3485 N P N L3500 N P N L3510 N P N L3520 N P N L3530 N P N L3540 N P N L3550 N P N L3560 N P N L3570 N P N L3580 N P N L3590 N P N L3595 N P N L3600 N P N L3610 N P N L3620 N P N L3630 N P N L3640 N P N L3649 N P N L3650 N P N L3660 N P N L3670 N P N L3700 N P N L3800 N P N L3908 N P N L3914 N P N L3916 N P N L4200 N P N L4350 N P N L4360 N P N L4370 N P N


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L4380 N P N L5000 N P N L5270 N P N L5300 N P N L6500 N P N L8000 N P N L8010 N P N L8020 N P N L8030 N P N L8100 N P N L8110 N P N L8120 N P N L8130 N P N L8140 N P N L8150 N P N L8160 N P N L8170 N P N L8180 N P N L8190 N P N L8200 N P N L8210 N P N L8220 N P N L8230 N P N L8300 N P N L8310 N P N L8320 N P N L8330 N P N L8400 N P N L8410 N P N L8415 N P N L8420 N P N L8430 N P N L8435 N P N L8440 N P N L8460 N P N L8465 N P N L8470 N P N L8480 N P N X0003 N P N X3610 N P N X3680 N P N X4280 N P N


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X4290 N P N X4800 N P A X4801 N P A X4802 N P A X4803 N P A X4804 N P A X4805 N P A X4810 N P A X4850 N P A X4851 N P A X4852 N P A X4853 N P A X4854 N P A X4890 N P A X4891 N P A X4892 N P A X6006 N M A X6460 N M A X7200 N M N X7300 N M N X7520 N M A X7533 N M A X8200 M D N X8334 N M A X8335 N M A X8336 N M A X8337 N M A X8338 N M A X8339 N M A X8433 N M A X8434 N M A


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NEW JERSEY ADMINISTRATIVE CODE

TITLE 10. DEPARTMENT OF HUMAN SERVICES CHAPTER 59. MEDICAL SUPPLIER MANUAL

APPENDIX B Current through July 16, 2001; 33 N.J. Reg. No. 14

FISCAL AGENT BILLING SUPPLEMENT AGENCY NOTE: The Fiscal Agent Billing Supplement is appended as a part of this chapter but is not reproduced in the New Jersey Administrative Code. When revisions are made to the Fiscal Agent Billing Supplement, replacement pages will be distributed to providers and copies will be filed with the Office of Administrative Law. For a copy of the Fiscal Agent Billing Supplement, write to: UNISYS PO Box 4801 Trenton, New Jersey 08619-4801 or contact Office of Administrative Law Quakerbridge Plaza, Building 9 PO Box 049 Trenton, New Jersey 08625-0049

chapter 59 medical supplier manual - new jersey...

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